Those of us with Chronic Disease often blame our thyroid for the many signs and symptoms we experience. Hair loss? Thyroid! Weight gain? THYROID! Fatigue? It’s gotta be the thyroid!
Treating hypothyroidism without treating the adrenals is one of the biggest reasons people continue to feel exhausted despite receiving treatment with thyroid hormones. Patients may initially report feeling more energetic after starting thyroid hormones, but this is usually followed by feeling worse and worse until they are right back to where they were before they started the thyroid medications. At this point, they will likely go back to their physicians to check blood work and will be told that everything is normal.
Many symptoms of hypothyroidism overlap with symptoms of under-active adrenals. However, physicians don’t routinely check adrenal function in those with Chronic Disease.
Symptoms of poor adrenal function may include the following:

• Feeling overwhelmed
• Feeling tired despite adequate sleep
• Difficulty getting up in the morning
• Craving for salty foods (a.k.a. the “I just ate a whole bag of chips syndrome”)
• Increased effort required for everyday activities
• Low blood pressure
• Feeling faint when getting up quickly
• Mental fog
• Alternating diarrhea/constipation
• Low blood sugar
• Decreased sex drive
• Decreased ability to handle stress
• Longer healing time
• Mild depression
• Less enjoyment in life
• Feeling worse after skipping meals
• Increased PMS
• Poor concentration
• Reduced ability to make decisions
• Reduced productivity
• Poor memory

Do any of these sound familiar?
The Adrenals at a Glance
The adrenal glands release hormones such as cortisol and adrenaline. These “stress hormones” impact many important functions throughout the body. They help establish your stress tolerance, tame inflammation, regulate blood sugar and body fat, control potassium and sodium levels (impacting blood sugar), and influence sex drive and anti-aging… among other things.
You may have heard that the stress hormone cortisol is “bad”. This is misleading — while high levels of cortisol are problematic, what could be equally or more problematic is having low levels of cortisol, especially when it comes to having an autoimmune disease and fatigue.
Cortisol is a hormone that is required for life — we could not live without it, and it is an important anti-inflammatory hormone. In fact, it gets released whenever we have inflammation to cool things down.
I have found that the majority of people with Chronic Disease have low levels of cortisol.
Testing for Adrenal Issues
In addition to looking at your symptoms (above), you can determine if you have adrenal dysfunction by utilizing the assessments below.
The Irritability Test
Irritability and overwhelm are two cardinal signs of adrenal dysfunction. My best test for determining adrenal issues is being snappy or short-tempered, feeling overwhelmed, or  finding other people annoying. For example, I can always tell that my adrenals are overwhelmed when my mom calls to say hello, and I feel like this is too much of a demand!
Blood Pressure Test
People with adrenal fatigue often have low blood pressure and/or a drop in blood pressure after standing up from a lying down or sitting position (orthostatic hypotension). If your blood pressure is below 120/80 mmHg, this may mean that your adrenals are under-active, or that you are dehydrated. Symptoms may include dizziness or lightheaded when standing up from a sitting/lying down position.
Pupil Contraction
People with low adrenal function may often have difficulty with contracting their pupils. Usually our pupils dilate (enlarge) in the dark, and contract (get smaller) in the light. Symptoms of adrenal dysfunction may include light sensitivity, difficulty seeing in bright lights, having to wear sunglasses on most days, or as I like to call it, feeling like a vampire in daylight!
Unstable Temperatures
If you are keeping track of your first morning temperatures, low and unstable morning temperatures may be suggestive of adrenal insufficiency. In contrast, pure hypothyroidism usually results in temperatures that are low, but rather stable, on a daily basis.
The “Whole Bag of Chips” Test
Have you ever eaten (or wanted to eat) an entire bag of chips in one sitting? You’re not alone! Salt cravings are a cardinal sign of adrenal issues. With adrenal issues, we may find ourselves with intense cravings for salty foods like crackers, chips, pretzels and olives.
Hormone Testing
Adrenal saliva tests provide a way to test our current adrenal function. These tests are generally only available from functional medicine and integrative health care professionals.
Normally functioning adrenals are supposed to put out the most cortisol in the morning, and the levels of cortisol should decline during the day until very little cortisol is secreted at bedtime. A cortisol kick in the morning helps us to get out of bed bright-eyed and bushy-tailed, ready to face the day. Low cortisol secretion at bedtime helps us relax and sleep.
Some people with adrenal dysfunction have the opposite pattern — they can’t get up in the morning and drag their feet until the early afternoon, feel slightly human for a few hours between 2pm and 8pm, then get a second wind at bedtime. These people often have a flipped cortisol rhythm, where their adrenals put out very little cortisol in the morning and too much in the evening, causing them to be alert and sleepy at the wrong times.
Other people may have abnormally low cortisol readings all day, everyday. These poor souls wake up tired and the fatigue lasts all day — I have been there, and it’s not fun. This low cortisol causes inflammation to go unchecked in the body, prevents healing, and causes the person to be sluggish for most of the day.
I recommend the Adrenal Complete Profile test from Ulta Lab. I have found it to be the most accurate for adrenal testing. However, the lab recently redefined their reference ranges, resulting in labs I would have previously classified as dysfunctional to be misread as normal by the untrained eye. If you’re going to go down the road of adrenal saliva testing, I recommend working with a practitioner trained in interpreting these labs, preferably one who has been interpreting them for at least 4-5 years.
What Causes Adrenal Fatigue?
In most cases of adrenal fatigue, the problems generally originate in a communication breakdown that occurs within the hypothalamic-pituitary-adrenal axis, otherwise known as the HPA axis. The HPA axis describes the interactive feedback loop that takes place between these three endocrine glands.
The hypothalamus is like the CEO of our body’s production of hormones. It scans messages from our environment and other endocrine glands, as well as checks the body’s overall hormonal status before passing on the order for more hormones to the pituitary gland. The pituitary gland then acts as a project manager and will pull together individual workers (like the thyroid gland, the adrenal gland, and the gonads) to do their jobs. The pituitary will also make sure the workers have adequate resources to do their jobs by managing growth (and repair), and electrolyte/water balance.
The HPA axis works in response to two types of stress: immediate stress and chronic stress. Let’s see how the responses to each type differ.
In cases of immediate stress, the hypothalamus senses stress and sets off a hormone cascade that leads to the activation of our fight or flight response. As part of this response, the adrenals pump out extra hormones and our bodies go from the state of relaxing, digesting and healing, to a survival state.
Your body’s energy is shifted from activities not essential to survival like growing beautiful hair, metabolizing nutrients into energy, making hormones, and digesting and repairing itself to instead focusing its resources to meet the great, stress-induced demand for cortisol and adrenaline.
Then, once you’ve escaped from the threatening bear or gotten out of the way of the oncoming car, the demand for emergency levels of hormones settles down and the focus once again turns to parasympathetic response, focused on body maintenance and upkeep.
In cases of chronic stress, the never-ending presence of stressful, yet non-life-threatening situations, can lead to the constant activation of the stress response.
To help meet the demand for cortisol, your body will decrease the production of other hormones normally produced by the adrenals such as progesterone, DHEA, and testosterone.
Eventually, with enough chronic stress, the HPA axis becomes overwhelmed and desensitized to the usual feedback loop and stops sending messages to the adrenals to produce more hormones or less hormones, no matter what’s happening. Additionally, a person may run out of nutrients that are required for proper adrenal function.
One of the most common causes of adrenal fatigue is stress, which creates an intense demand for stress hormones such as cortisol and adrenaline. There are four main types of stress to consider:

1. Sleep disorders
2. Mental/emotional stress
3. Metabolic/glycemic dysregulation
4. Chronic inflammation

Sleep Disorders: One of the fastest ways to induce adrenal dysfunction is through sleep deprivation. In fact, sleep deprivation is used in lab animals to suppress the hypothalamic-pituitary and adrenal axis (HPA) axis. Sleep deprivation can be caused by insomnia, sleep apnea and shift work.
Mental Stress: Feelings such as grief, guilt, fear, anxiety, excitement and embarrassment can be classified as stress. This stress is based on our perception, not on the nature of the individual stress. For example, public speaking may cause plenty of mental stress for someone with social anxiety, but another person who enjoys speaking in front of others may perceive the experience as pleasurable. Situations that are new, unpredictable, and threaten the ego, or that involve feeling a loss of control, are perceived as stressful.
Glycemic Dysregulation: Researchers in Poland have found that up to 50 percent of patients with Hashimoto’s have an impaired tolerance to carbohydrates. This means that after consuming carbohydrate-rich foods, their blood sugar levels would spike up very high, causing a great amount of insulin release. The role of insulin is to clear blood sugar out of our bloodstream and store it in our cells, so a large insulin release is followed by a rapid drop of blood sugar (hypoglycemia). Symptoms of hypoglycemia are very unpleasant and may include irritability, fainting, lightheadedness or tremors. Hypoglycemia necessitates the release of cortisol to help maintain the glucose supply to the brain and counteracts insulin, causing insulin resistance. (This is also linked to the Type 2 Diabetes epidemic).
Inflammation: Chronic inflammation may occur from joint pain, obesity, toxic burden, inflammation in the GI tract from irritable bowel disorders, pathogens, or food sensitivities. These conditions will signal cortisol for its anti-inflammatory effect.
Recovering From Adrenal Fatigue
There are six main pillars of my Adrenal Recovery Protocol:

• Rest
• Balance blood sugar
• De-stress
• Reduce inflammation
• Replenish nutrients
• Build resilience with adaptogens

Rest
Sleep is the reset button for the adrenals. When we sleep, our body releases human growth hormone and repairs itself. Make sure to get at least 7 hours of sleep each night and go to sleep before 10pm. If you can pull it off, I actually recommend getting 10-12 hours of sleep per night for 1 month in my adrenal-focused recovery protocols.
Balancing Blood Sugar
Stabilizing your blood sugar through diet is a crucial step in overcoming adrenal fatigue and thyroid conditions. Balancing your blood sugar can create noticeable improvements in how you feel each day.
Aim first and foremost to eat more fats and proteins, and less sugary and starchy carbs.  When consuming carbohydrate-rich foods, your blood sugar goes up too high, too quickly, causing symptoms such as nervousness, lightheaded, anxiety, and fatigue. These swings in blood sugar can weaken your adrenals and cause a spike in your thyroid antibodies.
Stress Reduction
The most important strategy for combating adrenal fatigue does not involve dieting, supplements, medications, or testing. This strategy, however, is often the hardest to implement.
That strategy is… stress reduction.
Reducing my stress was probably the hardest lifestyle change for me to implement. I only had two settings, “GO” and “SLEEP.” I did not know how to relax, smell the roses, turn-off, or unwind.
So, I came up with this list of strategies to make myself more relaxed and shift my body into a state of relaxing, digesting, and healing. I hope some of my strategies will resonate with you.  But, many of you will want to come up with your own list. Many of these items may be really difficult to implement, especially for those of us with responsibilities like jobs, children, or elderly relatives who need our care. However, somehow, you HAVE to schedule time for yourself.
We often expect our doctors to heal us, but the healing comes from within just the same. No one else will do it for you. Put it in your planner if you must.
Some strategies to reduce stress include:

• Do your best to eliminate, simplify, delegate, automate.
• Be more resilient by being more flexible. Bruce Lee once said, “Notice that the stiffest tree is most easily cracked, while the bamboo or willow survives by bending with the wind.”
• Do the things that you like.
• Avoid burning the candle at both ends.
• Massage, acupuncture, meditation or yoga may help get you relaxed.
• Avoid multitasking. Do one thing at a time and keep your full attention on it before you move on to the next task. Take a small break in between tasks.
• Start a journal, make your list, be mindful of what makes you feel better and what makes you feel worse.

Reduce Inflammation
Food sensitivities are a common source of inflammation. Gluten, dairy and soy are the most common reactive foods in Chronic Disease, and eliminating them will eliminate inflammation in your body. Elimination diets and food sensitivity testing may help you determine additional foods that may need to be removed from your diet.
Chronic infections are also a common source of inflammation in the body. Common infections include H. pylori, Blastocystis hominis and Candida, but there are numerous potential infections that can be root causes as well.
Replenish Nutrients
The salt cravings and feelings of dehydration that occur with adrenal fatigue are our body’s way of letting us know that we need more salt. Rather than reaching for processed foods or thyroid toxic iodized salt, including a good-quality sea salt in your diet may help if you feel a bit dizzy getting up in the morning or after a hot bath, or have other symptoms of adrenal fatigue. I like to recommend buying a pink or grey sea salt and making yourself a salty drink each morning and sipping it throughout the day. Homemade bone broths with plenty of sea salt are also a great and tasty way to rehydrate.
Supplements
While supplements often need to be individualized for people depending on their level of adrenal dysfunction (which needs to be determined via testing), I have found that most people with Chronic Disease feel better when they utilize the ABC’s of adrenal supplements.
The ABC’s are: Adrenal Adaptogens, B Vitamins, and Vitamin C.
Adaptogens
Adaptogenic herbs are any natural herb products that supplement the body’s ability to deal with stressors. In order to be considered an adaptogen, an herb must possess several qualities. First, the herb must be nontoxic to the patient at normal doses. Secondly, the herb should help the entire body to cope with stress. Finally, the herb should help the body to return to “normal” regardless of how stress is currently affecting the person’s functioning. In other words, an adaptogenic herb needs to be able to both tone down overactive systems and boost underactive systems in the body. Adaptogens are thought to normalize the hypothalamic-pituitary-adrenals (HPA) axis.
Adaptogenic herbs include: Ashwagandha, astragalus reishi mushroom, dang shen, eleuthero, ginseng, jiaogulan, licorice, maca, schizandra, spikenard, and suma. These are examples of herbs that may increase the body’s ability to resist stress, and have been helpful in relieving adrenal dysfunction when used in combination with vitamins and minerals.
B’s and C’s
Vitamin C and B Vitamins become depleted during high cortisol production. Pantothenic acid and biotin deficiency in particular have been linked to decreased adrenal function in animals and humans.
While some may wish to obtain these supplements from natural whole food sources, due to gut issues, people with Chronic Disease usually have an impaired ability to extract vitamins and minerals from food.
In comes Designs for Health Adrenal Complex. Designs for Health created the supplement Adrenal Complex to use a combination of the ABC’s I recommend for balancing adrenals: Adaptogens, B Vitamins and Vitamin C.
Alternative ABC Blend
HPA Adapt –This blend of adaptogenic herbs, vitamins, minerals, and amino acids is designed to support the adrenals and provide a powerful defense from the mental and physical factors associated with occasional stress. The formula synergistically supports mental relaxation while counteracting the metabolic effects of occasional stress as well.
In some cases, you may benefit from additional B vitamins and Vitamin C to support your adrenals.
Standalone B Vitamins
B Supreme – B vitamins play an important role in cell metabolism, thyroid function, and adrenal function. They become depleted in stressful situations that often precede the development of autoimmunity. Four especially important B vitamins are pantothenic acid (B5), thiamine or benfotiamine (B1), biotin (B7), and cobalamin (B12). This exceptional combination of B vitamins, including Vitamins B1, B2, B3, B5, B6, B12, biotin, and folate (as Calcium Folinate) should be helpful for most people with low energy levels. B vitamins are water-soluble vitamins and do not build up in the body, so the risk for toxicity is almost nonexistent.
Other Supportive Nutrients
Magnesium Citrate – As magnesium is depleted by stress and is often difficult to obtain from foods, most people will benefit from long-term supplementation. It is also excellent for promoting relaxation.
Vitamin C – Vitamin C is an essential vitamin for supporting adrenal function. I recommend doses of 500 mg to 3,000 mg per day, as tolerated.
Advanced Strategies
While many cases of adrenal dysfunction are caused by current stress and modifying those stressors can help with overcoming adrenal dysfunction, in some cases, additional interventions may be needed to address past traumatic stress, as well as chronically altered release of adrenal hormones.
Traumatic Stress
Traumatic stress may lead to a chronic pattern of adrenal hormone dysfunction. Various types of traumas and abuse have been tied to autoimmune conditions and thyroid hormone abnormalities. Many of my clients have experienced significant traumas such as the loss of a loved one and/or being in an abusive relationship before the onset of Chronic Disease. Some of us have also experienced childhood trauma, which can set the tone for altered hormone patterns in adulthood.
Resolving traumatic stress usually requires a targeted therapy (I prefer neurofeedback and EMDR).
Supplemental Hormones
A variety of hormones and adrenal-supporting substances may be used based on your adrenal testing or cortisol saliva test results and adrenal insufficiency stage.
Although most of these hormones are available over the counter at health food stores, they are certainly not benign and should be used under the supervision of a trained professional with extreme caution. Not everyone will need all of these supplements.
Your practitioner may utilize pregnenolone, DHEA, 7-Keto, adrenal glandulars and in some cases, the medication hydrocortisone to rebalance your adrenals.

References

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