Adrenal Fatigue is increasingly common, yet there still remains an unwillingness among medical doctors to diagnose it. There are essentially three reasons for this, and I am going to explain each of them on this page. Hopefully this will explain why your doctor may be so reluctant to make a diagnosis of Adrenal Fatigue.
Reason #1: Lab tests are inconclusive
The biggest obstacle to getting a diagnosis of adrenal dysfunction is the fact that lab tests are almost always inconclusive. Why is this? It’s because of the extraordinarily wide ranges that labs use as their reference ranges. In most cases they simply look at a cross-section of the population, measure their cortisol levels, and set the reference range at 2 standard deviations from the mean. In practice, this can lead to some extraordinarily wide levels.
Let’s look at two hormones that are absolutely crucial for our good health, but which often take a nosedive during advanced cases of Adrenal Fatigue. These hormones are DHEA and cortisol, and they are a great example of why you should never take the lab tests at face value.
The best way to measure cortisol is to test it at several points during the day, as our cortisol levels fluctuate naturally over a 24hr period. I also recommend getting a saliva test as they tend to be more accurate than blood tests. The cortisol reference ranges provided by Labcorp are as follows:
Cortisol Morning (lab range): 0.025 – 0.60 mcg/dL
Cortisol Noon (lab range): 0.01 – 0.33 mcg/dL
Cortisol Afternoon (lab range): 0.01 – 0.20 mcg/dL
Cortisol Evening (lab range): 0.01 – 0.09 mcg/dL
You can immediately see the problem here. A noon measurement of 0.01 will be ‘within range’, and so will a measurement of 0.33, despite being 33 times higher. To put it another way, your cortisol level could drop from 0.33 to 0.01 (a drop of 97%) and you would still be within the reference range. That just doesn’t sound right, and it’s exactly why any good doctor or naturopath will define an optimal range rather than simply use the one provided by the lab.
We see exactly the same story with DHEA. The reference range for DHEA is usually pegged at 280-640 mcg/dL for men and 65-380 mcg/dL for women, but the optimal levels are much tighter. In fact, the optimal range for women is actually higher than the lab ranges. Here are the optimal levels as provided by the Life Extension Foundation (LEF) – you can see that they are much tighter.
DHEA for men (reference range): 280 – 640 mcg/dL
DHEA for men (LEF optimal range): 400 – 500 mcg/dL
DHEA for women (reference range): 65 – 380 mcg/dL
DHEA for women (LEF optimal range): 350 – 430 mcg/dL
The wide ranges actually make it very difficult for doctors to treat their patients correctly. They are often told not to ‘overprescribe’ drugs to their patients, so how can they justify prescribing cortisol if their patient’s levels are within the range? It takes a very knowledgeable and well educated doctor to go against what the lab is telling him.
Cortisol Deficiency (Dr. Henry Lindner)
Cortisol in Blood (WebMD)
The 10 Most Important Blood Tests: DHEA (Life Extension Foundation)
Dehydroepiandrosterone (University of Maryland Medical Center)
Reason #2: Doctors are discouraged from diagnosing Adrenal Fatigue
The second reason is that medical doctors are simply discouraged from diagnosing adrenal fatigue. They are discouraged by the insurance companies, and they are discouraged by commercial pressures too. Let me explain why.
Firstly, you should know that each disease that is recognized by the insurance companies has a code. These codes are known as the International Classifications of Disease (ICD) codes, and they are administered by the World Health Organization. The latest version of these codes is named ICD-10. The problem is that although Addison’s Disease (severe adrenal insufficiency) has been assigned code 27.1, there is no code for Adrenal Fatigue (a milder adrenal insufficiency). In theory doctors could use code 27.4, Adrenocortical insufficiency NOS (not otherwise specified), but in practice this is difficult to justify when most lab tests come back as ‘within range’.
Although this might sound like more of a bureaucratic issue than a real problem, the consequences of ICD-10 are profound. Without an ICD code, doctors cannot claim payment from a patient’s insurance company. In other words, if they diagnose you with Adrenal Fatigue, they don’t get paid for treating you. This means that only the more enlightened (and less commercial-minded) doctors will consider a diagnosis.
There is another incentive for doctors to avoid an Adrenal Fatigue diagnosis. It is a notoriously difficult condition to treat – a good Adrenal Fatigue treatment often involves dietary changes, herbal supplements and possibly hormone replacement. It is often far easier and more profitable for doctors to treat the symptoms rather than the underlying cause. So, for example, you might get prescribed antidepressants or ADHD medicine to lift your mood and energy, while the real cause of your symptoms is left untreated.
Codes from ICD-10 (WHO)
ICD factsheet (WHO)
Reason #3: Inertia in the medical establishment
The irony is that Addison’s disease (severe adrenal insufficiency, when cortisol levels fall extremely low) is a well-accepted diagnosis in the medical world. Yet mild adrenal insufficiency (otherwise known as Adrenal Fatigue) is regarded as an invalid diagnosis. One example of this comes from the Hormone Foundation, part of the Endocrine Society, which wrote in 2010:
“Adrenal fatigue is not a real medical condition. There are no scientific facts to support the theory that long-term mental, emotional, or physical stress drains the adrenal glands and causes many common symptoms.” – Hormone Foundation
The problem with this statement lies in the fact that this same foundation readily accepts Addison’s disease as a diagnosis. So why shouldn’t it be possible to have a milder adrenal insufficiency? This tendency to only see things in black and white is a major reason why Adrenal Fatigue does not get diagnosed. In the words of Richard Shames, MD:
“Any doctor worth his/her salt understands that the term “adrenal fatigue” means mild adrenal insufficiency. The Hormone Foundation statement readily admits that adrenal insufficiency IS a real diagnosis. To me, they seem to be denying the possibility that some people might have a mild form of a real diagnosis. That’s short-sighted and excessively arbitrary.” – Richard Shames, MD
In time this will change. Take hypothyroidism as an example. A few years ago most endocrinologists refused to diagnose hypothyroidism if the patient’s blood tests came back within the lab reference ranges. Nowadays, those same endocrinologists are much more inclined to diagnose mild hypothyroidism if their patient’s levels are just at the lower end of the range. Unfortunately this evolution took around 20 years, so it might take some time for the same logic to be applied to Addison’s and Adrenal Fatigue.
Interview with Richard Shames, MD (About.com)
Myth vs. Fact: Adrenal Fatigue (Hormone Foundation)
What do I need to know about Adrenal Insufficiency (Society for Endocrinology)