I have been reading old posts by Dr. Marianco it's funny when one reads something that they don't have you just don't get it. So I have been re-reading on slow days like today. I was going over this post by the Dr.M I think you will find this very good.
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Quote:
Originally Posted by Matt Muscle
If someone finally determines that they are suffering from partial adrenal insufficiency. Would the use of low dose hydrocortisone further shut down the adrenals so that it would be difficult to get them working again if the HC therapy was discontinued? Should the use of hydrocortisone only be considered if all natural therapies to repair the adrenals has not worked? In other words once you start using it, you could be on it for life? Where as with TRT, most can stop the therapy and just return to baseline levels in time.
The following is Dr.'s reply.
The best initial sources of information which is also fairly easy to read are the books: "Adrenal Fatigue" by James Wilson, and "Safe Uses of Cortisol" by William Jeffries.
It is important to distinguish the terms "Adrenal Fatigue" vs. "Adrenal Insufficiency".
Adrenal insufficiency is an illness. It is recognized by endocrinologists. In many cases, it indicates the long-term need, if not life-time need to use hydrocortisone.
In adrenal insufficiency, either the brain cannot release enough ACTH or the adrenals cannot produce enough cortisol and other hormones to sustain life if under stress. In primary adrenal insufficiency, there is destruction of the adrenal glands to the point it cannot work, does not respond to ACTH. Secondary adrenal insuffiency has many causes. One is failure of the pituitary, due to a tumor, to produce ACTH. Another is the excessive use of hydrocortisone or prednisone - glucocorticoid steroids - which shuts the adrenal glands down either permanently or potentially for years. Adrenal insufficiency is life-threatening without treatment. In adrenal insufficiency, since the body cannot make adequate cortisol (e.g. the adrenals are shut down), a person could die without hydrocortisone treatment.
In adrenal insufficiency, only in cases where the adrenals can rehabilitate (e.g. excessive glucocorticoid use) can hydrocortisone be gradually withdrawn. That is iffy because it can be difficult if not impossible to restart the adrenal glands once it has been shut down. Thus excessive use hydrocortisone or prednisone or other glucocorticoid use runs the risk of developing a permanent disability and life-threatening illness.
There is no "partial" adrenal insufficiency. A person either has it or doesn't.
On the other hand, adrenal fatigue is not technically an illness. It is the condition associated with adrenal fatigue (e.g. depression, chronic fatigue syndrome, anxiety disorders, etc.) that recognized as the "official" illness.
In Adrenal fatigue, there is no destruction of the adrenal glands. The adrenal glands are not shut down. The brain works. The parts of the brain - called the hypothalamus and pituitary - work. Blood tests of cortisol and DHEA-s are usually within the normal range. Adrenal fatigue is a deviation from the mean which still usually remains within the normal range.
In normal function, the brain determines how much cortisol is needed to respond to stress and signals the hypothalamus to signal the pituitary to send out ACTH to tell the adrenal glands to make cortisol. The cortisol level is then monitored by the hypothalamus. The amount of ACTH is then lowered or increased to control cortisol production to the amount desired by the brain. ACTH also stimulates adrenal growth.
Adrenal fatigue is analogous to an overtrained muscle. The muscle still can work. However, it is weaker and may lose muscle mass because the owner of the muscle has not had adequate rest or nutrition to build the muscle either in strength or endurance. This is a principal known to bodybuilding. Any stress, positive or negative, results in stimulation of the adrenal glands to produce its hormones and to grow. Without adequate rest and nutrition, the adrenals (like a muscle) wears down and has more difficulty in producing its hormones.
When given a short period of rest (such as some sleep or lack of activity for a few hours), the adrenals can rally and produce enough hormones so that blood tests of cortisol, for example, are normal or even high (when stressed). But ultimately, the adrenals can be shown to have periods when it has difficulty producing cortisol and the other hormones. I liken this to the adrenals “sputtering” - as a car engine sputters when the electrical system (analogous to the adrenal glands) is not working well. The amount produced is usually not below the reference range of the blood test. If below the reference range, the adrenals have failed and you have adrenal insufficiency, which is life threatening. In adrenal fatigue, a person still makes enough cortisol to live - though their life is suboptimal (e.g. chronically bedridden, depressed, fatigued, etc.).
Adrenal fatigue can be thought of as a mental-physical illness since the brain is what is first affected by stress and is overwhelmed in controlling the stress to the point the brain sends excessive stress signals to the adrenal glands which causes adrenal fatigue. Without the brain, there is no stress felt by the body, there is no adrenal fatigue.
Mental disorders which I've found are associated with adrenal fatigue include: mood disorders, anxiety disorders, attention deficit/hyperactivity disorders, psychotic disorders, adjustment disorders, personality disorders - practically any mental illness where stress is a factor. The word "stress" itself implies tension, anxiety, irritability, anger, etc., which are symptoms of adrenal fatigue. As such, mental illnesses are also physical illnesses - the mind and body cannot be separated in function - both are intertwined.
In adrenal fatigue, the use of low dose hydrocortisone (determined by the physician) does not shut down the adrenals. The adrenals still function fully, though are fatigued. If hydrocortisone is withdrawn, the person still has the original functional state of the adrenals, or the improved state with time of treatment.
In adrenal fatigue, when hydrocortisone is added to treatment, the brain (hypothalamus, pituitary) senses the additional cortisol and sends less ACTH to the adrenal glands. This then reduces the activity of the adrenal glands. The total cortisol in the body thus remains the same with or without hydrocortisone. The main change with treatment of adrenal fatigue is that the adrenal glands do not have to work so hard. Over time, they get rest even when working, to the point they can be not fatigued and fully healthy. This assumes that the original source of stressed is reduced (i.e. the brain acts to reduce the stress that led to adrenal fatigue).
If stress is reduced significantly, treatment of adrenal fatigue may last usually two years or less. It is not a permanent treatment - unless one has severe, overwhelming, chronic, inescapable stress, which cannot be addressed behaviorally or socially.
There are numerous treatments for adrenal fatigue aside from hydrocortisone.
The first treatment for adrenal fatigue is enough rest (e.g. taking a vacation from muscle building exercise - a strong neuroendocrine stress). Years ago, before managed care came in, psychiatrists could hospitalize patients with severe depressions and other mental illnsses for up to two years. The patient would then be in a state of nearly complete reduction in stress - no responsibilities, not chores, no societal stresses, etc. The patient would be given intensive psychological therapy, support by numerous staff (in essence, a new family). That patient would often come out completely well. In retrospect, those 2 years of complete rest, therapy and support essentially also fully rehabilitated the adrenal glands, which is one reason the patient did so well. Of course, this is impossible in the “real world” and with managed care, today.
I am hesitant to give hydrocortisone to my young child patients with adrenal fatigue, given the politics and medico-legal aspects of treatment. In this case, I prefer treatment which helps the parents with parenting skills to help reduce patient stress, psychotherapy which helps the patient adapt to stress, possible medications to reduce perceived stress, and nutritional interventions to help address adrenal fatigue.
Which of the numerous treatments for adrenal fatigue to choose depends on the individual’s condition and situation. The treatment is individualized, customized, in conjunction with discussion with the patient. It does not always include hydrocortisone. A lot will depend on what the patient desires in treatment, e.g. some patients prefer “natural therapies” first.
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