ADRENALS FAQ–the most frequently asked questions
Below are some of the most frequently-asked questions by hypothyroid patients concerning the problem of adrenal fatigue…and answers are below. This was originally written by Bob, a man who has dealt with both hypothyroid and adrenal issues, and there are now updates as patients and doctors continue to learn.
1) What are the symptoms of adrenal problems?
2) How can I tell if my problems are adrenal, or thyroid?
3) What is Adrenal Insufficiency?
4) Is Adrenal Fatigue the same thing as Adrenal Insufficiency?
5) How do I test the condition of my adrenals?
6) Is saliva testing as accurate as blood labs for cortisol levels?
7) How can I produce all of that saliva to fill up the tubes?
8.) Can I test my cortisol levels if I am taking HC or Isocort or other adrenal glandular?
9) Will my Dr agree with the 24 hour cortisol test (saliva testing)?
10) Will my Dr agree to treat my adrenals?
11) What if my doctor refuses to treat my adrenals because I don’t have Addison’s?
12) Can you help me understand my 24 hour cortisol saliva labs
13) Is stress the only thing that causes Adrenal Fatigue?
14) I have bloodwork for the adrenals, can you help me interpret the results?
15) How can I order some lab tests?
16) Do adrenal glandulars work?
17) Isocort does not require a prescription – where do I get it?
18) What else should I be doing to help the adrenals?
19) What medications are prescribed for the adrenals?
20) How do I start HydroCortisone?
21) Where do you get the dosing information?
22) How do I dose 20mg, 25mg, or 30mg of HC?
23) Why take more HC in the morning?
24) Why can’t I take a lower amount of HC, such as 10mg per day?
25) What if I feel nauseated, or shaky?
26) Why do I have trouble sleeping after starting HC?
27) How can I tell if I am low on cortisol, or too much?
28) Aren’t steroids dangerous – don’t they have side effects?
29) If I take HC or Isocort, will it put my adrenals to sleep?
30) How much cortisol does the body normally produce?
31) What is stress dosing – what if I get sick?
32) What is the difference between Primary and Secondary Adrenal Insufficiency?
33) What causes Primary Adrenal Insufficiency?
34) What causes Secondary Adrenal Insufficiency?
35) How do I test for Secondary Adrenal Insufficiency?
36) Why does it matter if I am Primary or Secondary?
37) Will I be stuck on HC for life?
38) Will I be able to wean off the HC?
39) How do I wean off HC?
40) Will HC kill my immune system?
41) What is a physiologic dose of cortisol?
42) What precautions should I consider before starting HC?
43) Do some people have a reaction to the medication?
44) What is a “Thyroid Dump”?
45) What is an adrenal crisis? (AKA “addisons crisis”)
46) The HC doesn’t seem to last long enough – what is Medrol?
47) How do I dose Medrol?
48) Can I take time-release HC, Prednisone, or other steroid to treat the adrenals?
49) Are there other adrenal hormones that I need to worry about?
50) What are the symptoms of low aldosterone?
51) Why should I test renin along with aldosterone?
52) What sequence do I treat the hormones? What about the sex hormones?
53) Will hormone medication affect my blood pressure?
54) Do these hormones affect fluid retention?
55) Will I recover 100% and feel normal?
1) What are the symptoms of adrenal problems? Fatigue, anxiety, light-headedness, shakiness, dizziness, nausea, and difficulty dealing with stressful situations. Dr. Rind says “Most people have a mixture of poor thyroid and poor adrenal function rather than purely one or the other, and therefore a mixture of symptoms”. He also says that poor thyroid and/or adrenal function is the most common cause of low metabolic energy. Metabolism is defined as the chemical changes in living cells by which energy is provided for vital processes (Websters). Please refer to this chart of symptoms http://www.drrind.com/
2) How can I tell if my problems are adrenal, or thyroid? The body’s temperature drops as the metabolism drops. Low temperatures are caused by low thyroid. If the adrenal hormone cortisol is low, the average daily temperature will fluctuate when comparing one day’s average to the next. (See Discovery Step Two, number Four, here.) We are not talking about temperature changes during one day – it is normal to wake up with lower temperatures and hitting a peak in the later afternoon. Take your temperature 3 hours after waking, again 3 hours later, and again in another 3 hours. You average those 3 readings to get one single number for that day. Please read Janie’s page http://www.stopthethyroidmadness.com/temperature/ and follow her link to Dr. Rind. Look at his examples and download his blank chart. Begin filling in your temperatures. If you post a question about your dosing, someone is going to ask about your temps.
3) What is Adrenal Insufficiency? In 1855, Thomas Addison first described adrenal insufficiency, which was subsequently named after him. Originally, tuberculosis was the most common reason for the adrenal gland failure. Currently, Addison disease most commonly results from autoimmune destruction of the adrenal gland. The adrenal hormones Cortisol and Aldosterone are vital for life, so Addison’s disease can be fatal.
If you search for information on Addison’s disease, you fill find quotes such as this one: “Adrenal insufficiency occurs when at least 90 percent of the adrenal cortex has been destroyed.” http://endocrine.niddk.nih.
4) Is Adrenal Fatigue the same thing as Adrenal Insufficiency?
No. The person with Adrenal Fatigue may have less severe symptoms, and there are lots of shades of gray. Here is an example from a medical site: “A significant number of patients with partial loss of adrenal function (limited adrenocortical reserve) appear well but experience adrenal crisis when under physiologic stress (eg, surgery, infection, burns, critical illness)” http://www.merck.com/mmpe/sec12/ch153/ch153b.html
A person with a more serious case of adrenal fatigue may have chronic symptoms of fatigue. They may have symptoms associated with low blood sugar (one of cortisol’s jobs is to help regulate glucose). They may feel light headed upon standing, as another function of cortisol is to maintain blood pressure.
Dr. Ron Kennedy says “Addison’s disease is so rare, and adrenal fatigue so common, that I prefer to spend most of our space here on the latter. This syndrome is marked by loss of energy with the experience of fatigue and oversleeping”. http://www.medical-library.
Dr. Tintera was making comments like this way back in 1955 “a former hypothesis – that the adrenal cortex functioned according to the classic “all or none” law – is repudiated as being contrary to both clinical and experimental evidence. Hypoadrenocorticism may be congenital or acquired, complete or partial. The two former subdivisions frequently fail of recognition.” http://www.fred.net/slowup/tint01.html
Many members discovered their adrenal fatigue when they started thyroid medication – because the increased metabolism strained the adrenals. http://www.stopthethyroidmadness.com/things-we-have-learned Doctor Broda Barnes describes this in his lectures “And the thing that we have to think of very often, is a partial adrenal deficiency too. If the blood pressure of a patient is 100 systolic or below, I hesitate, in fact I won’t start them on thyroid, without giving them 5mg of prednisone at the same time. Because, if you raise the metabolism a little as we’re doing with the thyroid, you also have to have a little more secretion from the adrenal. The normal gland, can furnish it and do all right. But if the blood pressure is too low in the beginning, the chances are that this patient is going to get worse, about four days after you start them on thyroid, they will become worse than they were.” (5 mg of Prednisone is = to 20 mg of hydrocortisone)
5) How do I test the condition of my adrenals? Please read what Janie says here http://www.stopthethyroidmadness.com/adrenal-info/ If your doctor insists on blood tests for cortisol, that is fine – just order the saliva labs in addition so you can see the 24 hour cortisol rhythm. http://www.stopthethyroidmadness.com/recommended-labwork/
6) Is saliva testing as accurate as blood labs for cortisol levels? Yes. Here is an article citing many medical references http://www.diagnostechs.com/mainFrame.asp?refPage=http://www.diagnostechs.com/body_text/articles.htm
7) How can I produce all of that saliva to fill up the tubes? Sniff on a jar of pickles, relish, or a lemon. Dr Peatfield says to do the test under routine stress conditions, not on a relaxing day off.
8 ) Can I test my cortisol levels if I am taking HC or Isocort or other adrenal glandular? No. the medicine will throw off the result of the test. http://www.macses.ucsf.edu/
9) Will my Dr agree with the 24 hour cortisol test (saliva testing)? Mine did, he had the saliva lab boxes right in his office. You may have to drive to a larger city to find a doctor familiar with treating adrenal fatigue. You can order the lab test yourself, see what result comes back, and learn as much as you can about this condition so you will be an educated partner in your health care.
10) Will my Dr agree to treat my adrenals? Dr. Lam says “Unfortunately, conventional medicine only recognizes Addison’s disease as hypoadrenia, despite the fact that adrenal fatigue is a fully recognizable condition. As such, do not be surprised if your doctor is unfamiliar with this condition.” http://www.drlam.com/articles/
Some members, especially those that are shackled by the constraints of “health insurance” approvals, have difficulty when their doctor doesn’t recognize their condition. Please review this page http://www.stopthethyroidmadness.com/how-to-find-a-good-doc/ You can ask if the doctor is familiar with the book “Safe uses of Cortisol” by Dr Jefferies http://www.ccthomas.com/details.cfm?P_ISBN13=9780398075002 or the books by Dr Peatfield http://featherstone.bravehost.com/thyroid/peatfieldadrenal.html
11) What if my doctor refuses to treat my adrenals because I don’t have Addison’s? You might explain to him that even people with Addisons have varying degrees of hormone production, as per this guide that you can download “Addison’s disease is not an ‘all or nothing’ condition. In the early stages of the disease many individuals are still able to produce some cortisol and enough aldosterone. This is partly why individuals with the disease take varying amounts of medication and why the amount of medication you need may alter over the years.” http://www.addisons.org.uk/info/manual/adshgguidelines.pdf
12) Can you help me understand my 24 hour cortisol saliva labs? A normal cortisol rhythm is highest in the morning, tapering off later in the day. In the early stages of adrenal fatigue, there can be excessively high levels of cortisol as the body responds to stress. Dr Lam explains the stress response here http://www.drlam.com/articles/
STTM has a good explanation of lab results here.
As adrenal fatigue progresses, the cortisol rhythm becomes disrupted, and often “flattens out”. This can happen even with somewhat normal levels of cortisol being produced – but the “below normal” morning cortisol tends to indicate that there is a problem. Often the person lacks adrenal reserve. During times of stress the adrenals cannot produce the extra cortisol required by the body.
As the problem gets worse, the “flattened” cortisol rhythm becomes so severe that the pattern is “flat-lining” closer to the bottom of the chart. This person could be said to have Adrenal Failure, also known as Adrenal Insufficiency. The combined cortisol readings of all 4 points of the day (called the “cortisol burden”) will be below normal range. As the adrenal fatigue progresses, the amounts of DHEA produced by the adrenals often become lower as well. Dr Lam’s article explains the reason for this. Low DHEA can be a clue to the condition of the adrenals.
13) Is stress the only thing that causes Adrenal Fatigue? No – there are actually a number of things that can be wrong. Please keep reading, and we will explore some of the causes of adrenal problems.
14) I have bloodwork for the adrenals; can you help me interpret the results? Emedicine.com says this: The preliminary test for adrenal insufficiency is the measurement of serum cortisol levels from a sample of blood obtained in the morning. Because of variations in cortisol levels due to the circadian rhythm, blood should be drawn when the levels are highest, usually between 6:00 and 8:00 am.
- Morning cortisol levels greater than 19 mg/dL (reference range, 9-25 mg/dL) are considered normal, and no further workup is required.
- Values less than 3 mg/dL are diagnostic of Addison disease.
- Values in the range of 3-19 mg/dL are indeterminate, and further workup is needed.
Over the years, members have posted their lab results and symptoms on numerous adrenal forums. When the morning cortisol is not greater than 19 mg/dL the members tend to complain of low cortisol symptoms. In the book “Safe uses of Cortisol” Dr Jefferies says “It is important to be aware that test results that fall within the “normal range” do not rule out the possibility that a patient might have mild adrenal deficiency”. If you want to determine the CAUSE of adrenal problems, additional tests must be done prior to starting treatment. Please continue reading these FAQ’s for additional information.
15) How can I order some lab tests? STTM lists them here.
16) Do adrenal glandulars that I can get at a health food store work? There are some members with very mild cases of adrenal fatigue who feel some improvement from over-the-counter supplements, and especially if the supplement is adrenal cortex ONLY. When you take adrenal glandulars, you are getting the entire gland which can include adrenaline–the latter is not needed. For more serious cases of low cortisol, prescription HC is needed, or even the OTC Isocort.
17) Isocort does not require a prescription – where do I get it? It is not typically found on store shelves and must be ordered. Read this page for more on IsoCort http://www.stopthethyroidmadness.com/isocort/
18) What else should I be doing to help the adrenals? Good sleep is very important, and try to keep a consistent schedule every day. 1/2 teaspoon Sea Salt mixed with a large glass of water in the morning, and again later in the day. Small but frequent meals (to help with blood sugar). Vitamins including B-complex after meals. There are good recommendations from Dr Lam http://www.drlam.com/articles/
19) What medications are prescribed for the adrenals? In Dr Peatfield’s book, he says “Undoubtedly for the physician, the replacement of choice is hydrocortisone, since this though synthetically produced, is identical to naturally produced cortisone. http://featherstone.bravehost.com/thyroid/peatfieldadrenal.html Hydrocortisone requires a prescription, and is sold under the brand name Cortef, as well as the generic names such as “Hydrocortone”. Some patients do better with a Medrol because it has a longer half life. Keep reading for more information on Medrol.
20) How do I start HydroCortisone? http://www.stopthethyroidmadness.com/adrenal-info/how-to-treat
21) Where do you get the dosing information? At first, we went by Dr Peatfield’s book, where he promoted a small ramp up starting at 2.5. We since found that those low doses and ramp ups caused uncomfortable adrenaline surges. We then learned, as did Peatfield, that it’s better to “start on” 20-30 mg, with 25 and 30 being common starting doses. They need to be multi-dosed as explain on the How To Treat page. Raises only occur after doing the Daily Average temps.
22) How do I dose 20mg, 25mg, or 30mg of HC?
To dose for 20mg: 10 – 5 – 2.5 – 2.5 (4 hours apart, sooner if needed)
To dose for 25mg: 10 – 7.5 – 5 – 2.5 (4 hours apart, sooner if needed)
To dose for 30mg: 10 – 10 – 5 – 5 (4 hours apart, sooner if needed)
23) Why take more HC in the morning? To follow the body’s natural cortisol rhythm, which is higher in the morning. 10 mgs is the highest amount to take at any one time to prevent the shut down of the ACTH. You don’t want to dose too high in the morning, or the body will sense the extra cortisol and the pituitary gland will reduce it’s request for the body’s natural cortisol production – and this can make you tired later in the day.
24) Why can’t I take a lower amount of HC, such as 10mg per day? Dr Jefferies states: “Most patients can be maintained on between 20 and 30 mgs. daily in divided doses. Although some patients may feel well on less than 20 mg. daily, it seems preferable to give at least this much cortisol, even to patients with low adrenal reserve, because it takes the strain off of the residual adrenal tissue and provides for more functional reserve in times of stress. Under some circumstances, it appears to provide an opportunity for residual tissue to regenerate. A few patients with low reserve have demonstrated evidence of recovery of reserve after months of even years of such treatment, but most seem to require some replacement for the remainder of their lives.”
Keep in mind that when you take a small dose such as 10mg of HC per day, the body is going to sense that cortisol in the blood and “down regulate” it’s own production of cortisol somewhat. So it is not just adding to your cortisol, but reducing it to some extent at the same time. The same thing happens when you take thyroid hormones, the body lowers its own thyroid hormone production by lowering the TSH. But if the adrenal (or thyroid) hormones are below optimum levels, this is a decision the patient and doctor need to make.
25) What if I feel nauseated, or shaky? These are symptoms of low cortisol – you should take your next dose even if it hasn’t been 4 hours. Some people need to move their doses closer together, or switch to a longer lasting medicine such as Medrol. Shakes can also result from low aldosterone, which is mentioned later in the FAQ’s. Too much cortisol can cause shakes. Low blood sugar can cause shakes – and for persons with adrenal issues this can be a big problem. This is why Dr Lam (and others) stress not to skip breakfast, and eat frequent small meals.
26) Why do I have trouble sleeping after starting HC? When cortisol is too high, or low, it can affect your sleep. And when members comment that they have more trouble sleeping after starting HC, it is often within the first month as the body’s metabolism is starting to wake up. During this “honeymoon” period, it is important to get good sleep – even if that means slowing down on the “normal” dose schedule, or taking a sleep remedy such as melatonin.
There are a variety of published medical articles and books saying not to take HC past the afternoon – yet many patients find that after they become accustomed to the medicine this is not a problem. If you let your cortisol get too low at night, it can wake you up with low blood sugar symptoms. Eating a small amount of protein, and a small dose of HC as you are getting to bed may help you sleep.
27) How can I tell if I am low on cortisol, or too much? As mentioned before, take your temperature and see if the daily average is consistent day to day, within .2 degrees measured by a dependable thermometer. Do the “blood pressure test” to see if your adrenals are supported. In order to learn the symptoms of too much cortisol, please do a search for “cushings syndrome”.
It is vital for anyone on this journey to keep a daily log, a journal with how you are doing, your dosing schedule, and any changes that you make. Write something in it every day, and review what you wrote for clues if things aren’t going well. Resist the urge to change more than one thing at a time, and be patient. Don’t change your dosing every day – try to be consistent within medically accepted amounts.
28) Aren’t steroids dangerous – don’t they have side effects? Cortisol-type medications are often prescribed for arthritis, severe allergies and asthma because of their anti-inflammatory qualities. For someone with low cortisol, the info sheet from Merck puts this into perspective: Your doctor has prescribed Hydrocortone for you because your body is not making enough hydrocortisone, either because part of the adrenal gland isn’t working, or because of injuries, surgery or other stressful events. Steroids are also used by people with other illnesses. Some of the side effects and other warnings in this leaflet may apply more to them than to you. Because your tablets are being given to you to replace natural hormones that your body lacks, you should be less likely to get side effects.
“Cortisol is a normal hormone, essential for life.” McCormack Jefferies MD, Safe Uses of Cortisol
Doctor Lam says “Supplementing With Natural Hydrocortisone or cortisone acetate in doses of 2.5 to 5 mg two to four times a day (note: it usually needs to be higher) can be a safe and effective way to replenish depleted adrenals. However, this should be done under the guidance of a physician and it is a prescription drug.”
There is a potential danger if you start supplementing cortisol, then stop suddenly or skip doses. See “What is an adrenal crisis” below.
29) If I take HC or Isocort, will it put my adrenals to sleep? There are some doctors that simply do not prescribe HC, and warn their fatigued patient that it will put their adrenals to sleep. If the doctor tested the adrenals, he may find that patient is already suffering from low levels of adrenal hormone. They may already be “asleep”.
In his book “Safe Uses of Cortisol” Dr Jefferies says “It has been demonstrated that when subjects with intact adrenals receive less than full replacement dosages of cortisol, endogenous adrenal function is suppressed only sufficiently to achieve a normal glucocorticoid level. For example, subjects receiving 20 mg (5 mg. four times) daily of cortisol have their endogenous adrenal steroid production decreased by approx. 60%, and subjects receiving 10 mg. (2.5 mg. four times) daily have their adrenal steroid production decreased by approx. 30%.”
“endogenous” means “originating within or produced by the body”
“glucocorticoid” means “any of a group of corticosteroids (as cortisol) that are involved especially in carbohydrate, protein, and fat metabolism, that are anti-inflammatory and immunosuppressive, and that are used widely in medicine (as to alleviate the symptoms of rheumatoid arthritis)” (Websters).
But what if you do not HAVE a normal glucocorticoid level? There have been studies on Chronic Fatigue patients taking “hydrocortisone – 25 to 35 mg per day: leads to a 20 to 35% decrease in endogenous ACTH and cortisol production… After stopping, it may take several days to several weeks to recover the previous adrenocortical status.” http://www.intlhormonesociety.org/ref_cons/Ref_cons_3_mild_glucocorticoid_deficiency.pdf
30) How much cortisol does the body normally produce? In doctor Peatfield’s book, he says “The natural output of hydrocortisone is actually variable and may be as much as 200 mg. daily under stress and 40 – 6o mg. in a normal resting state. Obviously then, a dose significantly greater than 40 mg. daily will tend to take over the adrenal production of cortisone, and the adrenals could shut down completely. It must be said at once, so long as this suppression doesn’t last too long, the adrenals will pick themselves up again, and restart producing the necessary cortisone for themselves as before.” http://featherstone.bravehost.com/thyroid/peatfieldadrenal.html
31) What is stress dosing – what if I get sick? As Dr Peatfield just said, the body makes more cortisol during times of stress. In Dr Jefferies book he says “A patient with untreated mild adrenal insufficiency or low adrenal reserve may function reasonably well when environmental conditions are optimum but tends to tire more easily, and if strenuous physical exercise is undertaken or a meal skipped, hypoglycemic symptoms may develop. If an infection such as a common cold develops, symptoms tend to be more severe and last longer than in a person with normal adrenocortical reserve.” “When a patient with adrenal insufficiency encounters stress, additional cortisol is necessary to maintain normal health and sense of well-being.”
The first rule is to take as little as you need to get through the stress. This does NOT mean to run your body low on cortisol, but to only dose if you really need it.
ILLNESS: for colds or slight fevers unrelated to a flu take 20MG at the first sign of illness, even at bedtime. According to Jefferies some people need up to 80MG a day to get through an illness.
FLU: Take 20MG four times a day till symptoms subside. Flu viruses attack the adrenals and the cortisol directly so you need a lot extra for this.
DAILY STRESSES: At the first sign of nausea or shaking that can’t be controlled take 5MG, wait 20-30 minutes for it to work and if nausea or shakes are still present, take another 5MG, repeat till it stops. After a few such times you will learn the dose that works for you, usually 5-10 MG will handle most usual stresses.
SURGERIES: Make sure your anesthesiologist knows you have adrenal insufficiency! ASK for solumedrol in the anesthesia IV. It is a normal precaution they will readily do for you for safety.
EXERCISE: While it is preferable you do not exercise to the point of needing extra cortisol, some feel it is a necessity of life to continue strenuous exercising while on adrenal meds. If you are exhausted after exercise, or take hours to recover, STOP. You are doing more damage to your adrenals and are undoing any good you might be doing by treating them. If you just need energy boost to do light exercise, try 5-10MG before starting the exercise. The trick is to supply the cortisol before your adrenals are being beat up for not having it.
Tapering off stress doses: If over three days, then you must go down slowly, no more than dropping 5MG every 2-3 days, but if it was just 3 days then you can drop 10MG every 3 days. If you start to feel exhaustion or especially flu like symptoms, go back up immediately and slow the decrease down.
32) What is the difference between Primary and Secondary Adrenal Insufficiency? “Failure to produce adequate levels of cortisol can occur for different reasons. The problem may be due to a disorder of the adrenal glands themselves (primary adrenal insufficiency) or to inadequate secretion of ACTH by the pituitary gland (secondary adrenal insufficiency).” http://endocrine.niddk.nih.gov/pubs/addison/addison.htm
ACTH is an abbreviation for adrenocorticotropic hormone, produced by the pituitary gland, which stimulates the adrenal glands to produce cortisone. As you know, the pituitary also controls the amount of thyroid hormones by secreting Thyroid Stimulating Hormone (TSH). It is a similar concept.
There is no cure for Secondary Adrenal Insufficiency, the missing hormones will need to be taken for life.
33) What causes Primary Adrenal Insufficiency? Tuberculosis remains a cause of Addison’s disease in undeveloped countries, but the most common reason today is an autoimmune attack on the adrenal gland – which can be determined by blood test. Those situations will gradually destroy the adrenal glands. There can be lesser degrees of insufficiency of the adrenal glands – and you could say that if the problem is not a progressive destruction of the gland it is not addisons. In Dr Gerald Poesnecker’s book, Chronic Fatigue Unmasked, he talks about simple heredity – some people are born with weak adrenals. If you do an internet search using the terms “adrenal enzyme deficiency” you will discover that some people are born with genetic issues that affect the body’s ability to make cortisol (and sometimes aldosterone). This is not as rare as you might think: “The estimated prevalence is 1 case per 60 individuals in the general population.” http://emedicine.medscape.com/
These can be rather permanent – something to keep in mind if you have been trying to restore full adrenal function by taking supplements. The adrenal glands can also be affected by viral and fungal infections. Dr Hans Selye’s early work demonstrated how stress can affect the adrenal glands – and many doctors believe that this type of adrenal fatigue can be reversed.
34) What causes Secondary Adrenal Insufficiency? Low functioning of the pituitary (hypo-pituitary) can be caused by an impact to the head, a tumor on the pituitary gland, antibodies to the pituitary (no lab test for this), or simply being born that way. In the books by Dr’s Jefferies and Teitelbaum they discuss severe illness such as flu affecting the pituitary – adrenal hormone production. Some doctors believe that Epstein Barr and other viral infections can affect the pituitary gland, resulting in lowered request for cortisol.
35) How do I test for Secondary Adrenal Insufficiency? Someone with Primary Adrenal Insufficiency would have high levels of ACTH in the blood, but low levels of cortisol because the adrenals were failing. With Secondary AI, the amount of ACTH in the blood is below normal. The pituitary should be asking for more cortisol, but it isn’t. A “serum ACTH” test will help answer this question, and it should be done in the early morning.
Your Dr. may want to just check serum ACTH and Serum cortisol levels before ordering more tests – or the lab could draw blood for those tests and then proceed immediately to an ACTH stimulation test, where artificial ACTH is injected, and serum cortisol levels are measured from blood samples drawn after 30 and 60 minutes. If the amount of cortisol produced by the adrenals responds adequately to the injection, you will be able to learn if the problem is with the adrenal gland itself, or the pituitary.
Sometimes both can be a source of trouble – for example the low pituitary output of ACTH has gone on so long that the adrenal gland has atrophied. And there can be shades of gray with the pituitary production of ACTH. Hypo-pituitary problems are not always a simple “black and white” lab result. Dr Jefferies says “Mild secondary adrenocortical deficiency is characterized by a baseline plasma cortisol level either low or in the low normal range, but with a normal response to Cortrosyn stimulation.” (Cortrosyn is a synthetic acth that is injected to determine the adrenal gland’s response to stimulation).
The members of the hypo-pituitary forum are familiar with these various blood tests for adrenals, and the educational materials listed on that forum will help you to interpret your results.
Remember – you cannot test for cortisol or ACTH if you are already taking HC.
36) Why does it matter if I am Primary or Secondary? These concepts are important to understand, because you may be seeing a well meaning holistic practitioner who is selling you bags full of supplements to “heal” your adrenals – rather than doing a lab test to determine if there is a problem, and why. Some practitioners are vitamin experts – but unable to write the prescription you need, or order medical tests. There is no “cure” for secondary adrenal insufficiency, the replacement hormones need to be taken for life. Over-the-counter supplements will not provide the missing hormones, and will not restore your adrenal function to normal if you have secondary adrenal insufficiency. One medical site says that secondary adrenal insufficiency “is much more common than primary adrenal insufficiency and can be traced to a lack of ACTH.” http://endocrine.niddk.nih.gov/pubs/addison/addison.htm Remember, saliva based lab tests are great for measuring cortisol levels at various points in the day, but will not tell you if the problem is with the adrenal glands (primary) or with the pituitary (secondary). None of these tests can be performed while you are taking HC, IsoCort, or adrenal glandulars, or licorice supplements – so consider getting all testing done before starting medication.
37) Will I be stuck on HC for life? Maybe. It depends on the severity of your condition, and the cause of your adrenal problem. This is a decision that the patient and doctor need to consider before starting. My adrenal insufficiency was not diagnosed for many years. Taking the proper remedy was like putting on glasses, and being able to see clearly for the first time. You wouldn’t have a problem wearing glasses every day, if you needed them. If I don’t wear my glasses (or contacts) I cannot see well enough to drive. I am thankful to be born in a century where glasses are available, and I can buy pills to replace my missing hormones.
38) Will I be able to wean off the HC? In Dr Peatfield’s book he says “The length of time necessary to provide adrenal support is really infinitely variable. My normal practice has usually been to obtain the best result with thyroid and adrenal support, and after six or eight weeks, start to tail off the cortisone supplement. If there is no adverse result it may then be stopped – taking, say, four weeks in the process. Sometimes the patient starts to lose ground; and it must then be restarted, and in another eight weeks or so another attempt to tail off is made. Sometimes, the adrenals have been so badly hit that the adrenal support may be required for months; and if the adrenals never fully recover, for a more indefinite time. Again I emphasis, that if adrenal support is required, it must be given for as long as it takes; there is no risk to this since one is simply restoring the situation to normal, in the same way, and for the same reason, that thyroid support may have to be given indefinitely.”
***Patient experience has shown the need to be on HC much longer than 8 weeks.
39) How do I wean off HC? When all issues are corrected—high RT3, hypothyroid, low B12, and anything else stressing your adrenals, patients start to remove HC by 2.5, holding each removal for a good three weeks to give the body a chance to ramp up its own production. Starting the reduction with the latest dose and moving up is done by many patients. .
While on the reduced dose, be alert for the need to “stress dose” rather than suffer through symptoms of low cortisol. This will help your chances of successfully weaning off. And if you do wean completely off HC, be alert for the need to stress dose if there are signs of low cortisol during times of stress or illness. Many weaned patients will need to be on supportive vitamins and herbs, and avoid stress.
40) Will HC kill my immune system? Too much cortisol can suppress immunity, so it is listed as one of the possible side effects on the warning label. But if a person is low on cortisol, there may be other problems, as Dr Ron Kennedy says “Anyone who is especially susceptible to infections probably has weakened adrenals, thyroid gland, or both — therefore, a weakened immune system.” http://www.medical-library.
Dr Jefferies says “The mobilization of at least some of the components of the immune response may depend upon the presence of adequate cortisol, since adrenally insufficient subjects are not able to produce a normal immune response. Hence, administration of physiologic dosages of cortisol may help to prevent the lowering of resistance that enables an infection to start or, after an infection has started, may assist the immune response and enable the person to recover more quickly. If, however, an excessive amount of glucocorticoid is present before an infection develops, the immune response may be blocked or misdirected, allowing infections to develop and progress abnormally.”
Dr Jefferies also says “Most patients can be maintained on between 20 and 30 mgs. daily in divided doses.” From this, you could assume that doses beyond 30 mg HC would not be good for the body’s natural immune system.
41) What is a physiologic dose of cortisol? Dr Jefferies says “When applied to hormone actions, a “physiologic” dosage implies one that promotes normal function, whereas a “pharmacologic” dosage is one in excess of normal requirements and hence, one that might alter normal function.” Doses of HC up to 30 mg may be considered a “physiologic” dose per doctors Jefferies and Peatfield.
42) What precautions should I consider before starting HC? You should have enough medicine so that you never run out, and always take a few extra days worth of medication with you whenever you leave the house. Dr. Jefferies says “Patients with adrenal insufficiency should be cautioned to carry ID cards stating their diagnosis, treatment, etc.” A medical bracelet is a good idea. If a person is not going to be consistent with taking their medicine, skipping doses, or leaving the house without their pills, it may be better not to start. Some keep Hydrocortisone cream with them.
43) Do some people have a reaction to the medication? If someone is going to have an adverse reaction to HC, it will usually happen within an hour of taking the medicine. This is important to remember, because there is a completely different reaction that can happen a few hours after taking the medicine, which is a LOW CORTISOL reaction (different than a reaction to the medicine). The person’s ACTH will be lowered somewhat by the HC, then after a few hours the HC begins to run out, and the person may feel fatigue, nausea, or shaky. The solution is to take the next dose, and consider smaller doses closer together.
44) What is a “Thyroid Dump”? We used to state that those who have been low on cortisol may have had the thyroid hormones “pooling” in the blood, and the HC opens up the receptors to receive the thyroid hormones. Instead, the discomfort may be from adrenaline rushes. When that happens, you may feel extreme anxiety, racing heart, and/or other uncomfortable symptoms.
45) What is an adrenal crisis? (AKA “addisons crisis”) An abrupt life-threatening state which is caused by insufficient production of cortisol by the adrenal gland. A typical finding in Addison’s disease. Individuals who have been taking corticosteroids (glucocorticoids) for a prolonged period of time (weeks to months) are at risk for acute adrenal crisis if the medication is stopped abruptly. For this reason, corticosteroid medication are withdrawn slowly on a diminishing dosing schedule.
Symptoms include low blood pressure (shock), weakness, headache, vomiting, fever chills, tachycardia and sweating.
Treatment includes blood pressure support and intravenous hydrocortisone. Tachycardia means “Rapid beating of the heart, conventionally applied to rates over 100 per minute”
If you are consistent with your medication and always bring a pill box with you so that you can stress dose, you can avoid this problem. Persons with severe adrenal insufficiency are advised to wear a medical bracelet stating “adrenal insufficiency”
46) The HC doesn’t seem to last long enough – what is Medrol? Dr Peatfield says that HC is “not stored by the body and gets rapidly used; 2 or 3 hours will see it pretty well used up completely.” Some people metabolize HC faster than others. If a person has symptoms of low cortisol despite being on higher doses of HC, such as over 30-40 mg, they may want to talk with their doctor about trying Medrol. Depending on the persons metabolism, the 1/2 life of Medrol can range from 18 to 36 hours.
47) How do I dose Medrol? Conversion tables will tell you that 1mg of Medrol = 5mg of HC. Persons who are already on HC can gradually switch over to Medrol, and typically end up with about 6mg of Medrol spread out through the day. It does not need to be taken every 4 hours like you would with HC, but a typical dosing schedule might be 3 mg at wake, 2mg in the afternoon, and 1mg at bedtime. Talk to your doctor about this.
48) Can I take time-release HC, Prednisone, or other steroid to treat the adrenals? Although a number of members have tried time-release HC, we have not seen people staying with it. 1 mg of Prednisone is equivalent to 4 mg of HC, but is harder on the liver to process, so Medrol seems to be the better choice for long term cortisol replacement.
49) Are there other adrenal hormones that I need to worry about? Dr Lam says “As adrenal fatigue progresses to more advance stages, the amount of aldosterone production reduces. Sodium and water retention is compromised.. As the fluid volume is reduced, low blood pressure ensues. Cells get dehydrated and become sodium deficient.” http://www.drlam.com/A3R_brief_in_doc_format/adrenal_fatigue.cfm
Although the adrenals make more hormones than just cortisol and aldosterone, persons with severe adrenal insufficiency usually take simply cortisone, and if needed, supplement aldosterone with Florinef. Further information about aldosterone can be found here http://www.
50) What are the symptoms of low aldosterone? Persons with low aldosterone are unable to retain sodium, and it spills into the bladder, taking water with it. This results in frequent urination, dehydration, and heat intolerance. Electrolytes become imbalanced, resulting in muscle twitches, heart palpitations, and the pupils of the eyes are unable to stay “constricted” when subjected to light (they “flutter”). See the article above, and follow it’s links to learn more about aldosterone, and how to treat it.
51) Why should I test renin along with aldosterone? If you didn’t get a full range of adrenal tests to determine if you were Primary or Secondary adrenal insufficient before starting HC, you may be able to gain insight on this by testing Aldosterone with Renin. The article mentioned above will explain this for you.
52) What sequence do I treat the hormones? What about the sex hormones? If the adrenals are weak, it is best to treat the low cortisol before working up to high levels of thyroid medication. And it is best to fully support these 2 before attempting to supplement the sex hormones, as they can change after the adrenals and thyroid are supported. To put it another way, if there is an imbalance of the adrenal and thyroid hormones, it can cause problems with the other hormones. If you know that you have an imbalance, it is fine to address it, but be alert for changes as your treatment progresses.
53) Will hormone medication affects my blood pressure? Yes, cortisol and aldosterone both have a direct affect on blood pressure. Persons with adrenal fatigue typically have low blood pressure, but this is not always the case. If you have a history of high blood pressure, you should monitor this at least once a day and note what is going on in your journal. If you are on blood pressure medication, you should research how it may affect cortisol and aldosterone. If you are taking Florinef because of low aldosterone, the dose may need to be reduced in order to avoid raising a blood pressure that is already high.
54) Do these hormones affect fluid retention? They can, especially when aldosterone levels are not right. The very bottom of this web page has more information http://www.tuberose.com/Adrenal_Glands.html Low levels of thyroid can also cause fluid retention, and in turn this can raise blood pressure. Persons with these difficulties would want to note any changes in symptoms in their daily journal in order to learn what is helping, or worsening these conditions.
55) Will I recover 100% and feel normal? You want to feel better. If hormones are not balanced, some improvement will occur as you supplement those that are low.
Many of us suffer from other issues that are not strictly due to a hormone shortage. For example, Hashimoto’s is the leading cause of low thyroid. Many people with these thyroid antibodies can have other “autoimmune” disorders that affect their well being. We see a lot of people with hormone issues that also have diabetes. Or going through menopause.
After 6 months of adrenal and thyroid support, I noticed that my skin was no longer dry, cracking, and bleeding. These type of changes will help you understand that you have made progress. There may be other aspects that are not directly addressed, but you will have a better chance of success once the body’s metabolism engine is functioning.