Published June 20, 2018 After posting about my recent adrenal issues, I had a ton of requests asking me to share the steps I’ve been taking to reset my circadian rhythm and strengthen my adrenal glands. Before I do that, I’m excited to dive into the basics about what “adrenal fatigue” really is, as it’s such a popular concept yet at the same time extremely misunderstood. The symptoms and suffering are very real, but the cause is what’s controversial… even among practitioners! Are the adrenals truly “exhausted,” or is there a larger hormonal/gut/inflammation issue at play affecting the cyclical release of adrenal hormone? In the functional medicine community, adrenal health is taken seriously and salivary cortisol (the stress hormone produced by the adrenals) is often one of the first things tested when someone is experiencing unrelenting fatigue. When cortisol comes up low, especially in the morning when your levels should be peaking to get you out of bed, you may experience depression, fatigue, anxiety, insomnia, and seeeeeerious sugar/salt cravings. source: beyondgoodhealthclinics.com The doctors and practitioners that I’ve seen personally or learned from through online articles usually attribute low cortisol to one of three causes: Addison’s Disease – primary adrenal insufficiency. A severe or total deficiency of the hormones made in the adrenal cortex. This lack of hormone production is caused by physical destruction of the gland, typically due to autoimmunity, meaning the body makes antibodies that attack the adrenals (shouldn’t we be asking why?). So this one is an autoimmune disease in most cases, which is something I want you to keep in mind for a theory I’ll talk about in a second. Secondary Adrenal Insufficiency – In Addison’s disease, the brain is telling the adrenals to make cortisol via the release of adrenocorticotrophic hormone (ACTH) from the pituitary gland. Despite this signal from ACTH, the adrenals simply can’t produce hormones due to physical damage. Secondary adrenal insufficiency is different – the adrenals themselves are usually fine, but there is either a total absence or a suppression of ACTH production. Since as I mentioned, ACTH is made in the pituitary, anything that affects the pituitary or hypothalamus can dampen its production. Causes of this one include long term steroid use (i.e. prednisone), hypopituitarism (underactive pituitary gland), pituitary or hypothalamus cysts/tumors, and “some inflammatory diseases” according to NADF. This set off a lightbulb with me as I’m sure systemic inflammation even in those without “inflammatory diseases” could affect ones pituitary/hypothalamus signaling loop. And in fact, that’s exactly what I’ll be talking about today! “Adrenal Fatigue” – the mystery diagnosis where you’re not sick enough to be diagnosed with primary or secondary adrenal insufficiency, but have a ton of adrenal symptoms. This is where everything “looks” normal on the standard labs (for example ACTH production is fine, the pituitary is fine), but the person has either chronically low cortisol or a very distorted cortisol rhythm. There is no solid explanation for *why* the cortisol is low due to the various “normal” labs, and that is exactly what I want to dive into with this article. Let’s find the root cause. I recently revealed that my doctor found my morning cortisol output to be quite low, which explained why I was so tired for several months on end no matter how much I slept. Based on my numbers, he felt I was in ‘late stage adrenal fatigue’ heading towards the beginnings of adrenal failure after experiencing high stress (and therefore damaging high cortisol) for too long. He said that after months or years of chronic stress, your glands simply get ‘burnt out,’ as shown in the chart below. source: Dr. Lam At such a young age I found it hard to believe my adrenals were going to “fail,” although I knew the stress of the last few years had done a number on me. I do resonate a lot with this chart, and can pinpoint the time when I entered what Dr. Lam calls “Stage 2 adrenal fatigue” where you start self-medicating to boost cortisol with coffee, herbs, etc. I was never a coffee drinker until I absolutely NEEDED it after moving into my last apartment (which we now know had a big mold problem). Despite all my health issues growing up and the previous battles my adrenals had to go through dealing with dysfunctional childhood family dynamics, I believe the mold was the straw that broke the camel’s back for me and sent me into an adrenal spiral! SYMPTOMS My symptoms (which started in that apartment) were hair loss, fatigue even after sleeping, muscle soreness and aches after exercising that were a) far too intense for the level of activity performed and b) lasted too long meaning I wasn’t recovering properly, weight gain (which only worsened with intense exercise), swelling, puffy face, etc. The solution provided by that doctor was VERY low dose steroids – just enough hydrocortisone to mimic the levels of cortisol I wasn’t making – which did not feel right for me. I wanted to know why my body wasn’t making it in the first place. And in fact, I knew my body COULD make it if it needed to, just at the wrong time! At around 9pm I would get a “second wind” and feel awake/energized/cheerful for the first time all day: the way I should have felt in the morning. Because I didn’t want to be on low dose steroids for an undisclosed amount of time (or any amount of time for that matter), I started researching as much adrenal info as I could to hear different perspectives. If my adrenal and pituitary glands were not physically damaged, there’s no reason I would simply stop being able to make hormones, right? MY AUTOIMMUNE THEORY Autoimmunity is exploding right now. I can’t tell you how many people I know with Hashimoto’s thyroiditis, psoriasis, or rheumatoid arthritis. In fact, I myself have noticed some psoriasis-looking scales/plaques on my scalp (which I thought was just dandruff) after consuming gut irritants like alcohol. (And you guessed it – these scales started when I was in the moldy apartment. Mold can be a huge trigger that brings out underlying autoimmune susceptibilities). I was told by my family doctor when I was in my teens that “a lot of my symptoms seem to be autoimmune related, but we’d have to wait until further progression to get a diagnosis.” And that is exactly how autoimmune disease starts: very silently until something explodes and you can’t ignore it any longer. If you want to get an idea of just how prevalent autoimmune disease is, I suggest listening to Dave Asprey’s podcast episode where he interviews Dr. Tom O’Bryan, DC. In the episode, he states: “Autoimmunity is on the rise in the last 30 to 40 years. What most people, even doctors, don’t put together is this: we think the number one cause of morbidity and mortality is cardiovascular disease. Well, every doctor should remember from their studies that cardiovascular disease (aka atherosclerosis – the plugging up of your pipes), is immune driven. It’s an autoimmune mechanism. Therefore, this topic of autoimmunity really becomes a primary concern for all of us, but we’ve never looked at it that way.” [We must understand that this is prevalent in almost all of us – that the number one cause of death is an auto-immune mechanism.] He states that autoimmunity can go on and on within the body for years before you even have a symptom. It’s called “the spectrum of autoimmunity.” He talks about a mind-blowing study that was carried out in 2003 by Dr. Melissa Arbuckle, MD, PhD. “Dr. Arbuckle went to Veterans Affairs and looked for people with the autoimmune disease lupus. She found 132 people in just one VA center that were being treated for a diagnosis of lupus. Now, if they’re being treated in a VA center, they’re veterans and served in the armed forces, which means they had their blood drawn many times over the years when they were healthy. What most people don’t know is that the government has been saving and freezing most of that blood since 1978. They’ve got tens of millions of samples of our service people’s blood. Dr. Arbuckle knew this and she asked for permission to look at the blood of the currently diagnosed autoimmune patients with lupus when they were healthy and serving in the Navy, Coast Guard, or Army. What did she find? There are seven antibodies to lupus, and all seven antibodies were elevated years and years before there were ever any symptoms.” What’s even more shocking is that he says when you do the right testing, you will find somewhere between six to seven out of every 10 patients (aka 60-70%) have elevated antibodies to their own tissue. That’s how frequent it is. And the most common trigger for this autoimmunity? The reason that it’s on the rise in the past few decades? The chemicals in our environment, and most importantly the food on the end of our forks! Back to the point here: as I mentioned earlier, Addison’s Disease (the medically accepted form of adrenal fatigue where your adrenals are so destroyed that they can and will fail without treatment) is an autoimmune disease. The body is slowly eating away at healthy adrenal tissue which is making it impossible for the glands to produce enough hormone. And just like every other autoimmune disease, it is rarely recognized in its early stages. It’s caught so late because the symptoms mimic chronic fatigue syndrome, depression, or the flu. This leads me to wonder how many of us with adrenal issues are experiencing a much milder form of Addison’s where antibodies are affecting the adrenal glands’ production of hormones, but not yet destroying them? When you think of how many women have thyroid symptoms before getting properly diagnosed with Hashimoto’s it makes sense. Plus, those with one autoimmune disease are at a much higher risk of developing other autoimmune diseases. Dr. Gerald Mullin from Johns Hopkins says that statistically, somebody with an autoimmune disease is at risk of a total of 7 autoimmune diseases in his or her lifetime. Why is that?! Because autoimmunity is a body-wide problem. It’s a fire that is fed by things like inflammatory foods and chemicals, and if not put out can spread to other areas. At the core, an autoimmune thyroid condition is not a thyroid problem: it’s an immune problem. An autoimmune form of arthritis is not a joint problem: it’s an immune problem. The best way to tackle any of these is to calm down the immune response by pinpointing triggers and lowering inflammation, especially in the gut. The immune system needs to understand that it does not need to be overactive on high alert. (And if it does, for example due to a chronic gut infection that’s been hiding for a long time, you need to address that infection so that everything can finally settle down!) Long story short, I do suspect I have always had some sort of low grade autoimmunity issues. I have some theories as to what triggered these in the first place, but I’ll save that for another post. I do believe that my most recent trigger was the mold exposure, and since that coincided with my adrenal symptoms, I can’t help but wonder if my current adrenal issues have anything to do with autoimmunity (especially since I mentioned they don’t catch Addison’s until the glands are completely destroyed). For this reason, one of the first things I did to heal my adrenals was embark on the Autoimmune Paleo Diet (AIP). Since I have never been outwardly diagnosed with autoimmunity, this was not something I planned to do forever (as many AI sufferers do in order to manage their symptoms with diet). Instead, I used it as an “elimination diet” where I ate this way for 6 weeks, then one by one reintroduced all the triggering foods I had cut out. The AIP as an elimination diet is an incredible n=1 experiment to uncover YOUR unique food intolerances and inflammation triggers, because it cuts out ALL immune stimulating and commonly allergenic foods, including nuts, seeds, nightshades, dairy, gluten, legumes, soy, corn, grains, and more. I basically ate organic meat, fish, vegetables, fruit, sweet potato and plantains for 6 weeks, and it was the best thing I ever did because it showed me that I am highly sensitive to nightshades such as tomatoes, which were the culprit behind the psoriasis-like plaques on my scalp. I haven’t had an itchy head since! I am also intolerant to gluten, dairy, soy, corn, and cashews… and I’m still reintroducing so I won’t know for sure yet what else. This will be covered in far more depth via my part 2 post: how I’m healing my adrenal fatigue! (Diet was only one of the many things I did so I’m excited to share all these tips). THE REAL EXPLANATION OF “ADRENAL FATIGUE” Other than my autoimmune theory (which relates to what I’m about to say anyway due to inflammation and lifestyle/food triggers), I resonated most with Chris Kesser’s excellent article that pinpoints “HPA axis dysregulation” as the real issue behind adrenal fatigue symptoms. The body’s HPA axis is our stress response system – a glandular communication/feedback network where the hypothalamus, pituitary, and adrenal glands talk to each other in order to control their hormonal output. source: Integrative Theraputics This network is something we talk about often in school, as herbalists in a fast-paced world need to regulate and calm this system in clients presenting with immune system, sleep cycle, energy, and anxiety issues. I have a whole page of notes talking about what to do herb, lifestyle and supplement-wise when this axis is overstimulated and the person either temporarily stops producing enough cortisol or becomes cortisol resistant. As Kesser explains, it’s not that your adrenals CANNOT produce cortisol (unless you have full blown Addison’s disease). It’s that once you’re under continued stress for too long, your body naturally wants to protect you from the harmful effects of prolonged exposure to HIGH cortisol. As part of this protection, your brain (the HP part) downregulates the entire HPA axis and stops giving your adrenals the proper signals to produce cortisol, leading to levels that are unfortunately too low and cause the fatigue. On top of this, chronically high stress (and thus chronically high cortisol levels) can also lead to cortisol resistance, similar to insulin resistance, which again is a protective mechanism. Both insulin and cortisol are hormones that we need in small amounts, at the right times. High amounts for too long are incredibly damaging to our tissues, so our body develops this “resistance” at a cellular level. In the scope of insulin, this leads to diabetes as sugar can’t get into the cells and stays in the blood stream. You crave more and more sugar because you’re not getting the glucose where you need it on a cellular level. In terms of cortisol, this would arguably lead to “adrenal fatigue” as free cortisol may be high but the amount our receptors can “hear” is low. We crave more and more stimulants to raise our cortisol (like coffee) because we’re not getting the cortisol we already have where we need it on a cellular level. ROOT CAUSES OF “ADRENAL FATIGUE” AKA HPA AXIS DYSREGULATION So… what causes the HPA axis dysregulation that leads to low cortisol in the first place? 1. As I just harped on about, the #1 cause is stress. But there’s a catch! The proper way to look at this topic of “stress” would actually be “perceived” stress. This is so important because something that’s stressful for one person may not be stressful for another, and vice versa. This can be as simple as someone who beats themselves up in their head every day vs. someone who has learned how to exit the loop of negative self talk. Their lives may seem similar on the outside – nothing “major” is wrong – but on the inside, the level of perceived stress brought upon by the self is very different. This is not your fault and this is one of the first things I addressed when healing my adrenals by going to therapy. There’s also evidence that early-life trauma may lead to an over-reactive HPA axis later in life, contributing to anxiety and metabolic effects, which is another reason why a therapist who works on addressing early experiences and family relationships can be an important part of an adrenal or hormonal healing protocol. SOLUTION: Lower perceived stress through daily stress management techniques and a solid morning/evening routine. Enlist the help of a therapist, support group, counselor, or even friend to help you vent and develop coping mechanisms. If ready, dive into childhood trauma and healing techniques to recover from those experiences such as EMDR. Learn how to have fun again. Meditate in the way you see fit whether it’s classic silence or knitting or dancing. Exercise in whatever way you’re physically able to in order to relieve mental stress, even if that’s a short daily walk. More on solutions in my part 2 post about how I’m healing. 2. Inflammation – especially gut inflammation. Part of what was killing my adrenals was poor quality sleep, even though I could sleep foreeeeever and not feel rested. More on this in the next point (because there’s a lot you can do to improve sleep that doesn’t relate to physical inflammation), but this aspect of my poor sleep was related to my gut. Do you have trouble falling asleep? Does your bed feel unusually uncomfortable or you toss & turn all night aching in certain positions? Do you wake up in the middle of the night unable to get back to sleep? Is your sleep extremely light, disturbed by little things? Are you disrupted by getting up to pee frequently either right before you fall asleep or in the middle of it? If you answered yes to any of these, know that the problem could start in your gut, not your brain. As I mentioned earlier, I embarked on the Autoimmune Paleo Diet (AIP) in order to lower body-wide inflammation and heal my adrenals. I wanted to figure out which foods (even healthy ones) I was having immune or inflammatory reactions towards. A week into eating this way (where you don’t consume any of the most common allergens and gut irritants), I was sleeping like a BABY and it hasn’t stopped since. For me a major culprit was nightshades, which I was eating almost daily but learned through this diet that I’m extremely sensitive to. Inflammation that affects the adrenals can also be caused by hidden gut infections like SIBO, candida or parasites. You’d be shocked at how common this is (which is why I made the ParaPro formula specifically for parasites, candida and viruses). I can’t stress it enough: when your gut is inflamed, especially due to bugs irritating your lining, it jacks up allllll your hormones and makes it impossible to get proper rest. If you suspect you have SIBO, H. pylori or another stealth gut pathogen, seek out a functional medicine practitioner who can perform advanced stool/breath tests. Conventional stool tests never picked up ANY of my parasites, whereas functional labs (and one old-school doctor who literally took a rectal scraping and looked at it under a microscope) did. SOLUTION: Elimination diet to find out your unique food intolerances, then stick with an anti-inflammatory diet that works best for you. A low carb AIP diet with my specific tolerated reintroductions is working very well for me. Get tested for hidden GI infections and clear them up with herbs and/or medications if needed. You HAVE to address pathogens like candida, parasites, and bacteria before your HPA axis can heal. Take a probiotic to replenish and support a healthy microbiome. More in part 2! 3. Poor sleep quality This was a big one for me. How can your body repair itself and find hormonal balance if you’re never getting solid rest? I didn’t realize how bad my sleep was until I lowered inflammation eating AIP and experienced true, deep sleep for the first time in ages. This made me want to hack my sleep even more. In part 2 where I go into detail about how I’m healing, we’ll chat all about sleep masks, blue blocking glasses, blackout curtains, and making your bedroom a sanctuary. 4. Blood sugar dysregulation (highs and/or lows) Either too high or too low blood sugar will trigger inflammation – not to mention it creates problems with insulin and leptin signaling which can both effect the HPA axis that we’re trying to regulate. If your blood sugar is too high, adopting a low-carb paleo diet (or even keto if your blood sugar issues are serious) can be life changing. If it’s too low, eating smaller, more frequent meals can be extremely helpful which will also support your adrenals. SOLUTION: Get off the sugar once and for all and address binge eating/emotional eating/food or sugar addiction if necessary. Eat balanced meals with healthy fat to keep your blood sugar in check (my body works best low carb). 5. The big one… circadian rhythm disruption. I know this is last on my list, but for me it has been perhaps the most important other than diet. When my doctor wanted to give me steroids for my adrenals, I promised myself that I was going to do everything in my power to reset my circadian rhythm so that my cortisol production/HPA axis would regulate on its own. As I said, my morning cortisol was scary low, but I always felt that “second wind” at night around 9pm. This meant I had an inverted circadian rhythm. The blue line below shows how your circadian rhythm should look: peaking in the morning to wake you up, and lulling at night so that its seesaw hormone melatonin can take over. Mine was similar to the irregular orange curve, where I was tired all day then felt my first burst of human-ness at night. Circadian disruption is caused by not getting enough exposure to light at the right time during the day (the morning in particular), and getting too much exposure to light at the wrong times, like at night. (Hello blue light from our phones and TVs!) This is the reason for the modern epidemic of HPA axis dysfunction. Our bodies are designed to respond to light – it’s what our mitochondria reads to control every cell in our bodies. The solution is to bring yourself into the natural rhythm of light and dark, making SURE that you get very early morning light exposure to trigger your adrenals to start producing cortisol at the right time. The other side of this, of course, is reducing your exposure to blue light in the evening. I have a ton of tips that relate to resetting your circadian rhythm for part 2, including what time I’ve been going to sleep/waking up, exposing your eyes to the infrared light of sunrise, wearing orange glasses at night, brushing your teeth with the light off and more! STAY TUNED FOR PART 2… I hope this explanation of adrenal fatigue resonates with you and gives you some concrete solutions that you can start working on today. I’m looking forward to sharing more of what I’ve been doing at home to support my HPA axis healing!