Treatment included botanicals and nutrients designed to improve the stress response, as well as stress-reduction techniques and dietary changes to reduce dysinsulinemia. TJ was also advised to begin a fiber supplement and to completely eliminate from her diet the foods she previously identified as contributing to constipation. While constipation was most likely a function of food sensitivities, bowel flora imbalance secondary to stress may have been a complicating factor. At her ten-month follow-up, TJ was pleased to report on how much her life had improved with ongoing treatment. She also reported a 13-pound weight loss. Figure 2 showed normalization of all salivary cortisol measurements. However, results remained in the low-normal range. TJ also indicated that she required ongoing adrenal support to maintain energy The treatment plan was continued, with further follow-up laboratory testing ordered at six months.

Elevated TSH frequently accompanies adrenal hypofunction.In frank adrenal insufficiency with hypothyroidism, treatment of the thyroid alone may result in an adrenal crisis. Thus, evaluation of thyroid function is indicated in the adrenal fatigue patient (as is the evaluation of adrenal function in the hypothyroid patient.) Dysinsulinemia is also seen in adrenal insufficiency's which suggests that dysinsulinemia may also be present in adrenal fatigue.These latter two findings may have been associated with TJ's tendency to gain, rather than lose, weight, which is a more common sign of frank cortisol deficiency.

There are a number of possible reasons for the difficulty in accepting adrenal fatigue as a valid, measurable condition. First, the multiplicity of potential symptoms (Table 1), can make the diagnosis difficult. Also, objective diagnosis requires multiple measurements to capture perturbations in circadian cortisol. Since blood remains the gold-standard specimen, divided specimen collection is less likely to occur in routine clinical practice. Furthermore, since ranges set for blood cortisol are designed to capture frank deficiency excess states, subclinical deficiency may be missed. Saliva, while long-used in integrative circles, is a relative newcomer among specimen types. Although not frequently tested by conventional doctors, salivary cortisol is easily collected over time, at multiple points, allowing the results of its assay to capture subtle perturbations in circadian cortisol dysregulation. It has been reported that circadian assessments of cortisol using saliva and serum were shown to be correlated. In our experience, salivary cortisol reference ranges that include quintile rankings (a frequent tool used in research to sort data) have more subtle interpretive power. With greater acceptance of salivary cortisol testing, formal recognition of adrenal fatigue as a clinical entity may develop.

CONCLUSION

Fatigue and stress are common complaints, and they play a role in the majority of primary care visits. Far too often, however, the cause of the fatigue is never found. Perhaps as a result, more than half of all fatigue patients fail to return for follow-up visits, which may contribute to the high incidence of unfavorable outcomes found in this population.

The cluster of symptoms experienced by TJ is a common finding in any clinical practice. Without recognition of adrenal fatigue as a legitimate clinical complaint, TJ would have been one of the patients for whom no diagnosis was found. Fortunately, her clinician recognized her presentation as chronic stress-induced adrenal fatigue, and she performed the appropriate evaluations. TJ responded very favorably to a treatment program directed at supporting adrenal function and stress reduction; it was safe, straightforward and relatively easy to implement.