What is adrenal fatigue?

"Adrenal Fatigue" Is Not a Recognized Medical Condition

"Adrenal fatigue" is a term used in alternative medicine that has no scientific basis and is not recognized by any endocrinology society—it does not exist as a legitimate medical diagnosis. 1

What the Evidence Shows

A systematic review of 3,470 studies examining the concept of "adrenal fatigue" found no substantiation that it represents an actual medical condition 1. The review analyzed 58 studies that measured cortisol profiles in both healthy individuals and symptomatic patients, and found systematically conflicting results regardless of the testing methods used 1.

Key Problems with the "Adrenal Fatigue" Concept

• No validated diagnostic criteria exist: The term lacks any standardized definition or diagnostic framework recognized by endocrinology organizations 1

• Unsubstantiated testing methodology: The cortisol assessment methods promoted by practitioners claiming to diagnose "adrenal fatigue" are not endorsed by endocrinologists 1

• False premises: The underlying theory that chronic stress causes adrenal glands to become "exhausted" and unable to produce adequate cortisol is physiologically incorrect 1

What May Actually Be Occurring

When patients present with chronic fatigue, weight changes, low blood pressure, and other symptoms attributed to "adrenal fatigue," several legitimate medical conditions should be considered:

Actual Adrenal Insufficiency

True adrenal insufficiency is a serious, life-threatening condition that is entirely different from the mythical "adrenal fatigue." 2, 3

• Primary adrenal insufficiency (Addison's disease) involves destruction of the adrenal cortex, causing deficiency of cortisol AND aldosterone, with prevalence of 10-15 per 100,000 population 4, 2

• Secondary adrenal insufficiency results from pituitary or hypothalamic disorders affecting ACTH production 2, 3

• Glucocorticoid-induced adrenal insufficiency occurs after prolonged supraphysiological glucocorticoid therapy 2

Diagnostic Approach for Real Adrenal Insufficiency

If true adrenal insufficiency is suspected based on symptoms like severe fatigue (50-95% of cases), nausea/vomiting (20-62%), weight loss (43-73%), hypotension, or salt craving 2, 4:

1. Obtain early morning (8 AM) measurements of serum cortisol, ACTH, and DHEAS 2, 5

2. Interpret initial results 2, 5:

   • Primary adrenal insufficiency: cortisol <5 µg/dL (<138 nmol/L), elevated ACTH, low DHEAS
   • Secondary adrenal insufficiency: cortisol 5-10 µg/dL, low or low-normal ACTH and DHEAS

3. Perform cosyntropin stimulation test if morning cortisol is intermediate (5-10 µg/dL): administer 0.25 mg cosyntropin IM or IV, measure cortisol at 30 and 60 minutes—peak cortisol <500 nmol/L confirms adrenal insufficiency 5, 2

Other Conditions to Consider

When "adrenal fatigue" is suspected, the actual diagnosis may be 6:

• Cancer-related fatigue: Involves dysfunction of the hypothalamic-pituitary-adrenal axis, inflammatory processes, and circadian rhythm disruption 6

• Depression or anxiety disorders: Share overlapping symptoms with purported "adrenal fatigue" 6

• Sleep disorders: Can cause chronic fatigue misattributed to adrenal dysfunction 6

• Thyroid disorders: Hypothyroidism presents with fatigue, weight gain, and cold intolerance 6

• Chronic fatigue syndrome: A legitimate condition with specific diagnostic criteria 6

Critical Pitfalls to Avoid

• Do not delay evaluation for true adrenal insufficiency: If genuine adrenal insufficiency is present and untreated, patients can develop life-threatening adrenal crisis requiring immediate IV hydrocortisone 100 mg and fluid resuscitation 4, 2

• Do not use unvalidated salivary cortisol testing: The cortisol testing methods promoted for "adrenal fatigue" diagnosis lack scientific validation 1

• Do not prescribe glucocorticoids for "adrenal fatigue": This can cause actual iatrogenic adrenal insufficiency and serious complications 2

Bottom Line

The term "adrenal fatigue" should be abandoned in medical practice 1. When patients present with chronic fatigue and related symptoms, pursue evidence-based evaluation for legitimate medical conditions including true adrenal insufficiency (which requires specific biochemical confirmation), thyroid disorders, psychiatric conditions, sleep disorders, or chronic fatigue syndrome 2, 1, 3.