Think of adrenal fatigueas the "waiting room" for type-2 diabetes, hypothyroidism and heart attack. As a disease classification, it hangs out there with other "pre-" conditions like"pre-diabetes" and "pre-hypertension," and is a strong indicator of which direction a patient's health is headed; namely, down.
The exhaustion of the body's ability to react to the signals from the brain and pituitary gland inevitably contributes to disease states like type-2 diabetes, hypertension, and hypothyroidism. Because adrenal fatigue affects a cluster of body systems, treatment is incomplete if it just targets individual, dysfunctional pathways.
Adrenal fatigue patients can present with any of the following symptoms: constant tiredness, need for extra sleep, inability to cope with stress, reduced libido, low back pain in the area of the kidneys, sighing, yawning, recurrent infections, irritability, moodiness, and cravings for sweet foods.
It is important to differentiate adrenal fatigue from chronic fatigue syndrome, which is typically a post-viral fatigue syndrome characterized by disabling fatigue occurring chronically, after minimal exertion, and with duration of at least six months (Warrell DA, Cox TM, Firth JD, et. al. Oxford Textbook of Medicine. 2003: 860).
Saliva testing for cortisol levels and measurement of thyroid hormones in the blood are essential to establish the baseline diagnosis and to confirm the dysregulation within the endocrine system. But thorough treatment of a complex and sometimes tricky condition like adrenal fatigue involves more than simply boosting cortisol orother hormones. One needs to treat these patients with substances that simultaneously restore balance in multiple physiologic systems, in a multifaceted, complex way.
When a human body isn't functioning optimally, it is seldom the fault of a singledysfunctional pathway. More often, there are dysfunctional cascades occurring that criss-cross multiple pathways. Hormones exert their effects in large part as a result of their interaction with each other: For example, elevated estrogen will increase sex hormone binding globulin (SHBG), which will in turn, decrease thyroid hormone receptor activity.
Drugs typically regulate single, isolated pathways, and they can effectively manage one component or symptom, but may do little to improve the underlying multi-organ dysfunction. Herbs, however, contain multiple physiologically active compounds and bioactive metabolites that affect multiple pathways and physiological systems.
Herbal medicine is older than human civilization – animals as diverse as primates, deer, rhinoceros, and wolves deliberately consume plants to deal with bacteria, viruses, parasites, or worms (Engel.Veterinary Herbal Medicine.2007: 7-15).
Humans, too, have a long history of consuming plants to support health. Common herbs like Rhodiola, Korean Ginseng and Ashwaganda are excellent examples of plants that help the body maintain homeostasis, in part by managing cortisol. Traditional healers understood that nature has provided plants with complex biochemical systems for regulating their own physiology and increasing their odds of survival. When these biochemical components are then consumed by humans, they sometimes give the same effects and render the same benefits.
Assembling the Adrenal Puzzle
Adrenal exhaustion is complex, and requires a comprehensive, full-body diagnostic approach. You can use both phenotypic characteristics (weight, belly fat, hair loss), as well asreported symptoms (cold, irritability, fatigue, mild depression, chronic illness) to support diagnosis. Assessment of the patient's pattern of cortisol secretion can also be helpful.
Cortisol secretion is cyclic: rising in the morning and slowly falling in the evening. Salivary cortisol tests are a comprehensive, convenient, and cost-effective method for determining how much cortisol is circulating. This hormone enters the cells lining the salivary glands via passive diffusion. This process prevents proteins or protein-bound molecules from entering saliva, so cortisol measured in saliva is the active or "free" fraction.
In my opinion it is a reliable way to diagnose adrenal gland status. Based upon the results, I can usually make specific herbal and nutritional recommendations.
Herbs for adrenal health are best used in combination, and these combinations need to be individualized and tailored to each patient's specific needs and contraindications. For simplicity's sake, there are two ways to think about herbal treatment for adrenal fatigue: Herbs can be used to modulate adrenal secretion (i.e., a "tonic" approach) or to increase the body's ability to respond to stress (an"adaptogenic" approach).
What follows is a brief review of some of the most common and clinically effective herbs used in the treatment of adrenal fatigue.
Licorice (Glycyrrhiza glabra and G. uralensis) is truly a friend to the adrenal cortex. A staple of traditional medicine for adrenal insufficiency and ulcers, this herb contains triterpenoid saponins that influence cortisol-cortisone balance throughout the body. Glycyrrhizin is the main active compound in licorice. At higher amounts, however, it has a strong effect on the kidney and allows cortisol to interact with aldosterone receptors, which affects sodium/potassium balance and increases blood pressure. For this reason, patients taking higher amounts of licorice need to be monitored closely.
More is not always better and the adrenal benefits of licorice root are achieved with doses in the range of 1.75 - 5.25 g per day. Using standardized extracts, this equates to approximately 25-75 mg per day. Licorice root in tablet form, twice per day, morning and evening, usually delivers the proper dose level. Good quality liquid extracts are also available, and should contain around 30mg/mL glycyrrhizin.
Licorice has been positively linked to a range of other health benefits including better blood glucosecontrol and fat modulation, improved iron absorption, reduction of coughing, improved female hormone balance, decreased inflammation, healing of the gut lining, and mucoprotection (Mills S, Bone K. Principles and Practice ofPhytotheraphy. 2000: 465-75). The latter requires up to 15 g per day of a de-glycyrrhizinated licorice extract.
Ginkgo (Ginkgo biloba) is a common herb well known for its ability to enhance peripheral circulation and for its neuroprotective effects. Often overlooked is the fact that Ginkgo can favorably affect stress levels. In one study, it lowered cortisol levels in healthy patients undergoing glucose tolerance testing (Kudolo GB. Clin Nutr. 2006. 25(4) 606-16).
Ginkgo is commonly thought to be blood thinning; however, a recent meta-analysis showed that Ginkgo extract did not increase the risk of bleeding (Kellermann A, et al. Pharmacotherapy. 2011 May;31(5): 490-502).
Not all Ginkgo extracts are the same. I recommend products that are standardized to 24% ginkgo flavones and glycosides, and 6% ginkgolides and bilobalides. Ginkgo in tablet form is easiest to prescribe, however some older patients may have difficulty swallowing tablets, so a standardized liquid extract may be preferrable. Tablets and liquids are equipotent as long as they are standardized properly. Clinical studies validate the use of ginkgo extract in the dose range of 120 - 240 mg per day. It can be given in divided doses, i.e. morning and evening, either with or without food.
Ashwagandha (Withania somnifera) root comes from India's Ayurvedic medicine tradition. It is particularly useful for stress-induced sleeping problems. Interestingly, recent East Indian trials showed that Ashwagandha improves both DHEA-S and testosterone levels (Ahmad MK, et al. Fertil Steril.2010. 94(3):989-996; Mahdi AA, et al. eCam. 2009.8; Auddy B, et al. J Am Nutraceutical Assoc. 2008.11(1):50-56).
Ashwagandha is available in tablet, capsule and liquid forms. Withanolides, a type of alkaloid, are thought to be the main active compounds in Ashwagandha. This is a high-dose herb: we typically use an extract equivalent to 2 g of the whole root twice daily. Traditional Ayurvedic practitioners sometimes use up to 7 g per day. If insomnia or sleep maintenance are an issue for a particular patient, I advise taking Ashwagandha immediately prior to bedtime.
Korean Ginseng (Panax ginseng): The main root (not the lateral roots or root hairs) of this plant is traditionally used in western herbal medicine to remedy physical or mental exhaustion, lowered immunity and to facilitate adaptation to stress. In Traditional Chinese Medicine (TCM) it is considered a key herb for reinforcing vital energy and longevity (Mills S, Bone K. Principles and Practice of Phytotheraphy.2000: 418-30).
Recent human studies have expanded the therapeutic uses of Korean Ginseng to include improvement of insulin sensitivity, increased cerebrovascular circulation, better memory, improved cell-mediated immune function and reduced incidence of the common cold, reduced DNA oxidative damage in smokers, and symptom improvement in patients with depression, headache, insomnia and fatigue in women with menopausal symptoms (Morgan M. A Phytotherapist's Perspective #137. June 2011. www.mediherb.com).
The evidence is in favor of using standardized main root extracts. The recommended dose is 100 mg, 1-4 times daily. Patients with insomnia should take Panax ginseng no later than midday. For those without sleep problems, morning and early evening doses are usually well tolerated.
Eleuthero (Eleutherococcus senticosus) is an adaptogen herb used to support cognition, alertness, immune function, and physical stress. The most recent research on adaptogens views them as stress mimetics and focuses on their ability to increase levels of stress protective heat shock proteins. In other words, adaptogens act like mild stressors to the body, and the body's protective response is what accounts for the therapeutic benefits (Panossian A, Wikman G. Curr Clin Pharmacol. 2009.Sep;4(3): 198-219).
People often ask if thereis a difference between Eleuthero and Panax Ginseng. The benefits of both herbs are similar and very complementary. However, there are differences: Eleuthero is suggested for patients who are stressed and/or suffering recurrent infections; Panax is best for older patients (40+) as a whole body and healthy aging tonic.
Rhodiola (Rhodiola rosea) is another adaptogenic herb with a long history of traditional use. It also has a number of positive human trials in the areas of stress and fatigue management, enhancement of mental performance and treatmentof mild depression. Rhodiola exerts these beneficial effects by regulating key mediators of the stress response including cortisol, nitric oxide, molecular chaperones (HSP70) and stress activated protein kinases.
The anti-depressive effect is in part associated with its effect on monoamine oxidase A and up-regulation of HSP70. (Panossian A, Wikman G, Sarris J. Phytomedicine. 2010: 481–493). Rhodiola has been used successfully to increase stamina, prevent fatigue, improve mental function, reduce anxiety and ameliorate symptoms of mild depression. It combines well with Ginseng for additional vitality and endurance. I typically use 3-12 g per day of a high-quality Rhodiola rosea root extract, containing rosavins and salidroside.
Rehmannia (Rehmannia glutinosa) is an herb used extensively in Chinese medicine. It is similar to licorice and can be used as both a tonic and as specific support for the adrenal glands. It is helpful for people suffering general debility, adrenal depletion, and poor immune system function, specifically in the contextof autoimmune disease. I generally recommend 750 – 2,250 mg per day of a standardized extract in tablet or liquid form. Up to 4 g per day are used traditionally (Mills S. Bone K. Principles and Practice of Phytotheraphy. 2000: 519-522).
Astragalus (Astragalus membranaceus) also comes to the West through its long use in Chinese medicine. It is typically used in combination with other herbs, especially Rehmannia and Eleuthero. Astragalus is both a tonic and an adrenal support herb. Its key bioactive components are polysaccharide fractions, isoflavonoids, saponins, triterpenoids, and gaba-aminobutryic acid. These substances can affect growth hormone levels, blood glucose, general inflammation, blood pressure, blood flow, and water balance in the body (Mills S, Bone K. Principles and Practice of Phytotheraphy. 2000: 273-77).
Astragalus can be combined with Eleuthero and Echinacea for patients who are 'run down' and experiencing recurrent respiratory infections. Combination formulas containing these three herbs are available, in both liquid and tablet form. Recommended daily dose is between 2.5 - 3.4 g. Patients will typically start to feel the benefits in 4-8 weeks.
Putting the Herbs to Work
All of these herbs have diverse qualities which can be combined depending on a patient's specific conditions and desired health goals. Licorice may provide immediate relief with quick, noticeable results. Gingko is excellent for enhanced blood flow and anti-oxidant protection. Ashwagandha supports the restoration of inner core for strength, libido, and endurance. Korean Ginseng is excellent for supporting adrenal and thyroid function.
The combination of Ashwagandha and Korean Ginseng is excellent if a patient's budget is tight. Each has adrenal restorative properties on its own, but they complement each other when combined. Another good budget option is Eleuthero, as it can beuseful to boost energy. Rhodiola may help for improving mood, depression and libido, and it cannot be beat for improving mental clarity!
Rehmannia can be effective for reducing inflammation and adrenal fatigue from a hypothyroid and hyperthyroid etiology. It also contains multiple naturally-occurring vitamins, giving it added value. Astragalus is helpful in supporting patients who feel tired, trying to struggle through their days.
Patients may experience many different outcomes when taking these herbs. For some, the benefit shows up as "not feeling tired and not crying for no reason." Others experience improved energy, absence or lessened depression, elimination of hopelessness, and an ability to think clearly and solve complex decisions. Normalizing cortisol secretion over the course of the day will often improve sleep patterns, as a result of the natural drop in cortisol at bedtime.
It took a lot of stress to reach the point of adrenal fatigue, and the problem cannot be resolved overnight. Patients need to understand that herbal therapies for adrenal fatigue usually require 30 to 60 days for noticeable effects. For some, the chronic cloud of exhaustion and helplessness may lift in about 30 days, but many will need to continue on for another 30 days before they really start to feel better.
Getting Patients Out of the "Waiting Room"
If adrenal fatigue is, indeed, the "waiting room" for more serious disorders, your goal as a clinician is to help the patient back through the front door and into healthy living. Herbal interventions are only part of the treatment plan. Patients must also learn to better manage their stress, set regular patterns for sleep, work, and meals; exercise every day (aerobic every day, strength training every other day); and add 15 to 30 minutes of relaxation (meditation, relaxing leisure activity) into their daily schedules.
I also recommend that patients avoid caffeine, sugar (especially juice, soda, and alcoholic beverages), deep-fried food, and processed meats and cheeses. Vitamin C is essential in adrenal restoration as vitamin C is consumed voraciously by the adrenal gland.
It is very important to help these patients to look at their physical and mental stressors, and to figure out ways to modify to decrease elevated cortisol. Lifestyle factors cause the stress that feed the vicious circle of endocrine instability.
That said, without help, sleep, and in some cases supplements, very few people are able to actually change their cortisol triggers. A low glycemic diet and exercise are essential for stress (cortisol) reduction and they're likely to have their greatest impact in early-stage adrenal fatigue, before the patient progresses into debilitating chronic fatigue syndrome and fibromyalgia.
It is important to understand---and help patients understand---that the hormonal and physiological processes underlying this condition are cyclic and inter-connected: increased cortisol leads to increased adrenaline, which over time leads to dysregulation of glucose metabolism. This domino effect of hormone dysregulation typically results in obesity and thyroid dysfunction, via enhanced production of even more cortisol.
Herbal interventions are safe and effective tools for helping your patients exit the waiting room of serious disease and re-enter their lives.
Michael Greer, MD, is an integrative medicine specialist focused on holistic, herbal, homeopathic, and naturopathic solutions for health. He incorporates the best of conventional medicine with natural medicine products and philosophies. Following a 20-year career as an OB/GYN, Dr. Greer is now focused exclusively on educating physicians about integrative medicine. He is an educator for Standard Process Inc. (www.standardprocess.com), the exclusive US distributor of MediHerb herbal supplements (www.mediherb.com) which are availablethrough healthcare professionals only.