www.drtomsalchemy.com
Stress, Fatigue
and
The Adrenals
Tom Archie, MD
St Luke’s Wood River
Family Medicine
When My Patients Visualize Stress…
When I Visualize Stress
Outline of this Presentation
 Differential
Diagnosis of Fatigue
 Hypothalamic– Pituitary – Adrenal Axis

Physiology of Chronic Stress
 Chinese
Medicine
 Relaxation Techniques
 Four Cases
 Supplements
 Summary
Fatigue Differential Diagnosis
 Depression,
anxiety, anemia, thyroid
disorder, insomnia, infection, sleep apnea,
alcohol overuse, mitochondrial
dysfunction, heart failure, menopause,
pregnancy, domestic or workplace abuse,
celiac, irritable bowel syndrome,
inflammatory bowel disease, medications,
autoimmune disease, hypogonadism, B12
deficiency, malnutrition, electrolyte
abnormality
Tests that can Help Narrow the
Differential Diagnosis List
 Complete
blood count
 Electrolytes, liver enzymes, urinalysis
 Thyroid assessment*
 Serum or salivary cortisol, DHEA-Sulfate,
17-OH progesterone
 Questionnaires
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Beck’s Depression Index
Metagenics Stress IdentiT Protocol
Medical Symptoms Questionnaire
If all you have is a Hammer
Everything looks like a Nail
- Look Before You Leap Don’t jump from symptom of Fatigue to
Thyroid
Adrenal
Candida
Depression
Cancer
Without Considering and Evaluating Thoroughly
Chronic Fatigue Syndrome

Four or more of the following symptoms that persist
or recur during 6 or more consecutive months of
illness and that do not predate the fatigue:

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Impaired short-term memory or concentration
Sore throat
Tender lymph nodes
Muscle pain
Multijoint pain without swelling or redness
Headaches of a new type, pattern, or severity
Unrefreshing and/or interrupted sleep
Postexertion malaise lasting more than 24 hours
Exclusion criteria:

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Active, unresolved or suspected disease that is likely to cause
fatigue
Psychotic, melancholic, or bipolar depression (but not
uncomplicated major depression)
Psychotic disorders, Dementia, Anorexia or bulimia nervosa
Alcohol or other substance misuse
Severe obesity
Major Depression

Five or more of the following symptoms during the same 2week period and one of the symptoms is either (1) depressed
mood or (2) loss of interest or pleasure.
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Depressed mood (sad, empty, irritable or tearful most of most days
Loss of interest or pleasure in most activities on most of most
days
Change in Weight of >5% in a month or change in appetite
Insomnia or hypersomnia nearly every day
Psychomotor agitation or retardation nearly every day (others
observe restlessness or slowing down)
Fatigue or loss of energy nearly every day
Feelings of worthlessness or inappropriate guilt most days
Difficulty thinking/concentrating, or indecisiveness most days
Recurrent thoughts of death or of suicide without specific plan
Clinically significant distress or impairment in social,
occupational, or other function
Not due to the direct physiological effects of a substance abuse
or medical condition
Fibromyalgia

Widespread body pain present for at least 3 months

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Strongly tender 11 of 18 tender points (9 bilateral)
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Both sides of the body
Above and below the waist (low back considered below waist)
Includes axial skeletal pain (cervical spine, anterior chest,
thoracic spine or low back pain)
Occiput - suboccipital muscle insertions
Low cervical - anterior aspects intertransverse spaces C5/7
Trapezius - midpoint of the upper border
Supraspinatus – origins near the medial border of scapula
Second rib - upper lateral to the second costochondral junction
Lateral epicondyle - 2 cm distal to the epicondyle
Gluteal - outer quadrants of buttocks in anterior fold of muscle
Greater trochanter - posterior to the trochanteric prominence
Knee - medial fat pad proximal to the joint line
Acupuncture: GB20,BL10,GB21,SI13,KI27,LI10,BL53,GB30,LR8
Mayo Clinic on “Adrenal Fatigue”
www.mayoclinic.com May 2010
“Proponents of the adrenal fatigue diagnosis claim this is a mild
form of adrenal insufficiency caused by chronic stress. The
unproven theory behind adrenal fatigue is that your adrenal glands
are unable to keep pace with the demands of perpetual fight-or-flight
arousal. As a result, they can't produce quite enough of the
hormones you need to feel good. Existing blood tests, according to
this theory, aren't sensitive enough to detect such a small decline in
adrenal function — but your body is.
It‘s frustrating to have persistent symptoms your doctor can't readily
explain. But accepting a medically unrecognized diagnosis from
an unqualified practitioner could be worse. Unproven remedies for
so-called adrenal fatigue may leave you feeling sicker, while the real
cause — such as depression or fibromyalgia — continues to take its
toll.”
Lacking in curiosity – Excessive in sarcasm
Adrenal Fatigue
It’s not a Diagnosis
-
It’s a Function
Functional Medicine Matrix
www.functionalmedicine.org
Perspective

“Adrenal Fatigue” is not a standard medical
diagnosis


Therefore often dismissed by doctors
Closest is “Adrenal Insufficiency” which is of much
greater pathology and less common
• Inherited deficiency of enzyme needed to make adrenal
hormones

“Adrenal Fatigue” is a real and common
phenomenon, but the term is often misused to
encourage purchase of supplements instead of
lifestyle changes.
Perspective
 “Adrenal
Fatigue” describes the same
process known as “chronic stress”


Elevated cortisol in response to stress
Can lead to depression
• Depression, Chronic Fatigue, and Fibromyalgia
have a common root = prolonged elevated cortisol
due to chronic stress
 Term
“Adrenal Fatigue” coined by James
Wilson, ND in 1990s
Perceived Stress
 Origin

Physical, metabolic, psychological, emotional
 Timing

Acute and short lived
versus

Chronic, persisting, and unrelenting
Section that follows credited to excellent chapter by Michael Lumpkin, PhD
Lumpkin M. The Hypothalamic Pituitary Adrenal Axis. Textbook of Functional
Medicine. Ed. Jones D. Institute for Functional Medicine. 2005
Stressors
(Extensive research citations exist for the stressors listed below.)
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Sleep deprivation
Financial stress
Poverty
Conflict (interpersonal, business)
Persecution (domestic violence, incarceration)
Death
Divorce
Moving/Relocating
Attachment to Emotional Responses to Events
Chronic Pain
Chronic Illness
Hypothalamic Pituitary Adrenal Axis
Cerebral Cortex
Hypothalamus
Pituitary
Adrenal sits on Kidney
Stress Response - Hypothalamus
 Endocrine

System’s Command Center
Monitors neuronal, hormonal, metabolic and
immune signals within the body
compares them with

Signals from receptors for temperature, pain,
pressure, electrolytes
blends this information with

Higher cortical brain’s state of mind
• Fear, depression, agitation, anger, humor,
contentment
Hypothalamus
Produces “master” hormones called Releasing
Hormones
 Communicates to Pituitary Gland
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Corticotropin Releasing Hormone – “CRH” (Adrenal)
Thyrotropin Releasing Hormone (Thyroid)
Prolactin Releasing Hormone (Breast)
Gonadotropin RH
• LH and FSH - Testes, Ovary
• Growth hormone – skeletal/muscle growth, liver effect on
sugar levels
Releasing Hormones
 Messages
to Pituitary gland (intermediary
for the other endocrine organs)

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Stress response, reproduction, metabolism
(including thyroid), growth regulation,
lactation, balance of water/electrolytes
Regulates feeding, appetite, drinking, sex
behaviors, emotions, hormonal rhythms
Event Data mixes with
Emotional Response

Cortex – higher brain
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Observes factual data from events
Sends this via neurons to hippocampus & amygdala
Hippocampus
• Learning and memory transferred to long term memory

Amygdala
• Emotional responses are ATTACHED to factual info
The Root of Suffering is the Attachment to Emotions
We often confuse our emotional response to an event
with the data about the actual event
And
We hold tightly to our attachment to our emotions
Problem is not the emotion – it is the attachment to the emotion.
Biofeedback

Hippocampus and Amygdala send neurons that
converge on Hypothalamus

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In response to a blend of sensory information and
emotional assignment to that data, Hypothalamic
Releasing Hormones produce body changes
Neurons from Hypothalamus also project up to
higher cortical brain

This way, individual can notice changes in arousal
• Respiratory rate, muscle tremor due to fight/flight hormones,
alertness, body temperature, sweating, cold hands, dry
mouth, changes in appetite and thirst, bowel discomfort

Individual can CHOOSE to observe and act to change
the response – this is natural Biofeedback
Hypothalamic Pituitary Adrenal Axis
Cerebral Cortex
Hypothalamus
Pituitary
Adrenal sits on Kidney
Hypothalamic Pituitary Adrenal Axis
 Corticotropin

Pain, trauma, infection, low blood pressure,
exercise, low blood sugar, grief, loss, anger,
fear causes hypothalamus to release CRH
 Anterior

Releasing Hormone (CRH)
Pituitary responds by secreting
Adrenocorticotropic Hormone (ACTH)
• Also called “Corticotropin”
ACTH –
Adrenocorticotropic Hormone (aka Cortitropin)
 Turns
cholesterol into adrenal steroids
 First into Pregnenolone, then by adrenal
zone…into…

Mineralo-corticosteroids (aldosterone)
• Electrolyte balance – salt reabsorption in kidney

Gluco-corticosteroids (cortisol)
• Glucose regulation, immune suppression

Androgenic steroids
• Androstenedione >Testosterone > Estrogens
• DHEA-Sulfate
Cortisol
 Stress
increases metabolic demand
 Cortisol ensures adequate glucose and O2
to vital organs

Brain, heart, lung, muscle
 Cortisol

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helps aldosterone
Increase renal sodium reabsorption
Allows increased blood volume
CRH > ACTH > Cortisol release

Normal response to acute stress

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Cerebrum, hippocampus, amygdala > hypothalamic
release of Corticotropin Releasing Hormone
Cortisol rises until concentration high enough to
produce negative feedback to hippocampus and thus
to the hypothalamus to reduce CRH secretion - no
prolonged cortisol excess
Abnormal condition – prolonged stress

Damage and death to negative feedback neurons in
the hippocampus that help reduce CRH - sustained
cortisol elevation
Sapolsky RM et al. Endocr Rev. 1986;7:284-301

Stress > Adrenal Medulla produces Epinephrine &
Norepinephrine > leads to ACTH release by Pituitary
 Additional release of cortisol
Prolonged Stress – Cortisol
 Cortisol
rises with acute stress, then drops
 Cortisol stays high with chronic stress

“I feel stressed most days.”
 After
variable period of time (years)
cortisol then drops to low levels

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“I feel fatigued most days.”
Time to get to a low cortisol depends on
individual’s constitution and type of stressors
and frequency of exposure to stressors
Chronic Stress
Prolonged Elevated Cortisol

Increasing glucose levels
 Fat redistributes

From thigh/buttocks to abdomen & lower neck

Insulin resistance, fluid retention, high blood
pressure
 Decline in musculoskeletal quality and function

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Proteolysis of muscle, bone, connective tissue
Inhibits protein formation
Orth DN, Kova WJ. The Adrenal Cortex. Williams Textbook of
Endocrinology. 9th Ed. 1998:517-664.
Chronic Stress- Immune Dysfunction
 Reduced

number & function of…
Lymphocytes, eosinophils, basophils,
monophils, macrophages, neutrophils
 Reduced
production of immune cell
signaling molecules
 Reduced antibody production
 Increased frequency of infectious disease
Munck A et al. Endocr Rev. 1984;5(1):25-44
CRH and Adrenaline
 Corticotropin
Releasing Hormone increases
sympathetic (fight/flight) and reduces
parasympathetic (calming) outflow from brain
and spinal cord

Increases epinephrine & norepinephrine (NE)
from adrenal medulla
• Which further increases ACTH secretion by pituitary

Increases NE & neuropeptide Y in the….
• Heart, peripheral vessels, kidney, lung, pancreas, GI
tract, testicles, ovaries
• Whole body effects
CRH and Adrenaline
 Result
of increased CRH release by
hypothalamus

Increased pulse, heart contraction strength,
blood pressure, respiratory rate, liver release
of glucose and fatty acids, kidney secretion of
anti-diuretic hormone, and blood volume
 Other
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effects of chronic stress/cortisol/CRH
Thyroid function decreased
Reproductive hormones disrupted
CRH, Adrenaline, and the Gut
 Gastrointestinal

effects
Stomach
• Reduced gastric contractility
• Reduced gastric emptying

Colon
• Increased colon motility
• Rapid transit times
• Poor absorption of nutrients and water

Bloating, fullness, diarrhea, cramps,
exacerbation of IBS and Crohn’s Disease
Tache Y et al. Am J Physiol Gastrointest Liver Physiol. 2001;280:G6173-77
CRH, Adrenaline, and the Gut

Persistent stress reduces growth of probiotic
bacteria (good bacteria)
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Lactobacillus
Bifidobacteria
And increases growth of potentially pathologic
bacteria
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E. Coli
Clostridia
Enterobacter
Lizko NN et al. Nahrung. 1984;28:599-605
Adrenal Fatigue Observations
on Physical Exam

Achilles' tendon reflex slow, low amplitude
 Slow pupillary reflexes
 General quality of integument is poor
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Ridged nails
Hair thinning
Creased/lined fingerprints
Pale line above vermillion border
No citation – observation shared with other physicians following this topic
Prolonged CRH = Depression

CRH injected into animals’ brains
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Increased locomotor activity (escape)
Startle response
Anxiety
Stress-induced fighting (increases with dose)
Reduced appetite, avoidance of unfamiliar or
threatening locations
Sutton RE et al. Nature. 1982;297:331-33
Lenz HG et al. Horm Metab Res. 1987;16(suppl):17-23

These are the features of human depression
Prolonged CRH = Depression
 Depressed
humans have sustained 24hr
elevations of cortisol
 Depression
pattern is blocked with CRH
receptor blockers in experimental animals

CRH receptor blocker drug named “Antalarmin”
Chrousos GP, Gold PW. JAMA. 1992;267(9):1244-52
Habib K et al. PNAS. 2000;97(11):6079–6084
High HPA Axis Activity
Low HPA Axis Activity
(Elevated Cortisol)
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(Low Cortisol)
Chronic Stress
Melancholic Depression
Anorexia
Type 2 Diabetes
Syndrome X
Premenstrual Syndrome
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Adrenal Insufficiency
Chronic Fatigue Synd
Fibromyalgia
Postpartum Depression
PTSD
Rheumatoid Arthritis
exacerbation
Chrousos GP, Gold PW. JAMA. 1992;267(9):1244-52
Depression/Anxiety & Heart Health

Depression and anxiety increase the risk of death
after heart attack and can lead to diabetes

Exercise works as well as pharmaceutical drugs
for depression at 4 months

Drugs worked more quickly but effects equal at 4 months
• Blumenthal JA et al. Effects of Exercise Training on Older Patients with
Major Depression. Arch Intern Med. 1999;159:2349-2356.
• Frasure-Smith N, Lesperance F. Depression and Anxiety as Predictors of 2Year Cardiac Events in Patients With Stable Coronary Artery Disease. Arch
Gen Psychiatry. 2008;65(1):62-71
• Carney RM, et al. Depression and five-year survival following acute
myocardial infarction: a prospective study. Journal of Affective Disorders,
2008. doi:10.1016/j.jad.2007.12.005
Emotion and Heart Health

High levels of anger

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3.15-fold increase in future heart disease
Dose-dependant (more anger = more risk)
Kawachi I et al. Circulation. 1996;94:2090-95

Strong experience of anxiety

3.2-fold increase in heart attack risk
Kawachi I et al. Circulation. 1994;90:2225-2229
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Excessive worry
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2.4-fold increase in heart attack risk
Kubzansky LD et al. Circulation. 1997;95:818-824
Emotion and Heart Health
 Positive Affect
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“Feelings that reflect a level of pleasurable
engagement with the environment” (environment =
everything outside the self)
Happiness, joy, excitement, enthusiasm, and
contentment
65-99yo with higher positive affect 53% (half) as
likely to die in 2 yr study
Ostir, GV. J Am Geriatric Soc 2000;48:473–478

660 adults median age 63. Above-average
positive affect group lived 7.5 years longer than
unhappier half.
Levy BR. J Personality and Social Psychology 2002;83:261–270
Emotion and Heart Health
 Happiness produces…
 Lower cortisol on working and nonworking
days, reduced fibrinogen stress responses,
and lower ambulatory heart rate in men.
• Independent of age, socioeconomic status,
smoking, body mass and psychological distress.
Steptoe A.Neurobiology of Aging 26S (2005) S108–S112
Theory of Progesterone Steal
(aka: Pregnenolone Steal - or - Estrogen Dominance)

Adrenal Fatigue assumes an inability to keep up
with cortisol production demanded by continued
hypothalamic CRH elevation
 Progesterone (+/-pregnenolone) is “stolen” to
make more cortisol
 Low levels of progesterone out of proportion to
estrogen levels = Estrogen Dominance


Reinforced by chronic stress causing increased
central abdominal fat
This fat increases total body estrogen
Theory of Progesterone Steal
(aka: Pregnenolone Steal - or - Estrogen Dominance)

Complicated perimenopausal anovulation

Ovulation leaves behind the corpeus luteum which
secretes progesterone for the premenstrual week,
“runs out” of progesterone, and triggers menstrual
period

This theory presumes that fixing adrenal function
and estrogen dominance go hand-in-hand
 I can find no studies (See Case 4)

My Clinical experience – progesterone is calming
• Less insomnia & anxiety, reduction in hot flashes
Theory of Progesterone Steal
(aka: Pregnenolone Steal - or - Estrogen Dominance)

Progesterone is metabolized in the liver to
allopregnanolone which is a GABA receptor
agonist



Calming
Helpful for anxiety, insomnia, hot flashes
Topical progesterone bypasses the liver
• No studies on its effect on GABA receptor
• My clinical experience – topical progesterone easily adjusted
to produce same effects above

Is supplemental progesterone effective because
of its primary action as a GABA receptor agonist
or because it is replacing a deficiency created by
chronic stress response by adrenals?
Chronic Stress and Thyroid

Hypothalamic CRH neurons project onto
hypothalamic Thyrotropin Releasing Hormone
(TRH) neurons that govern pituitary’s release of
Thyroid Stimulating Hormone (TSH)
 Chronic stress reduces TRH …lower thyroid fxn

Low TSH, normal T4/T3 levels associated with
increased mortality in >60yo humans
• Indicator of chronic stress

Adding thyroxine (T4) in borderline hypothyroidism is
no better than placebo for cognitive function, mood, or
wellbeing
Pollock MA et al. BMJ. 2001;323:891-95
Upstream Antecedents
Downstream Diagnosis
Chronic Stress
CRH elevation
Cortisol elevation
Depression, anxiety,
fatigue, IBS, hypothyroid
Insomnia, central weight,
diabetes, PMS, high BP
polycystic ovaries,
heart disease
Chinese Medicine and Adrenals
Chinese Medicine and Adrenals

Debate: The Root of All Disease boils down to
one of two schools of thought
 Kidney Jing (dependent on KI Yin)
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Ancestral/genetic inheritance
Lifestyle stress, Adrenal Fatigue
Enters body at conception
Leaves body with last breath
Spleen Qi

Three Treasures
Jing
Qi
Shen
Dependent upon and responsible for proper nutrition,
gastrointestinal function, and immune function
Chinese Medicine and Adrenals
 Adrenals

are part of the Kidney
Kidney is the solid organ manifesting the
Water Element
 Adrenal
Deficiency ~ Water Deficiency
• Kidney Yin Deficiency
• Kidney Yang Deficiency

Underlying any Yang Deficiency is Kidney Yin Deficiency
Fire
Wood
Five Elements
System of
Correspondences
Water
Earth
Metal
Homeostasis
Sheng – Ke Cycle
Supporting or
Augmenting Influence
Controlling or
Dampening Influence
System Self-Correction
(in the short term)
Five Element Correspondences
 Water

(Kidney, Bladder)
Philosopher, contemplative, remarkably strong
or weak motivation/willpower, sensitive to guilt
and fear, hurt deeply by abuse, bladder
infections, kidney stones, incontinence, joint
pain, low back pain, inner chill, music, hearing
problems, throat, winter, black, north, salty, cold
or heat intolerance
 Adrenal
Gland governed by Water Element
• Symptoms produced by imbalances in Wood and
Fire Elements triggered by Water deficiency
Five Element Correspondences
 Wood

(Liver, Gallbladder)
Driven, multiple projects, movement, CEO,
anger/anxiety, tight traps/lateral neck/IT band,
TMJ, migraine, headaches, caffeine
sensitivity, fibromyalgia, blue/green,
sour/citrus, Spring, expansion, insomnia (esp.
sleep maintenance 11pm-3am), east
Five Element Correspondences
 Fire
(Heart, Small Intestine, Pericardium,
Triple Energizer)

Creative, CEO, joy, awareness,
love/attachment, mania, palpitations,
insomnia (esp. sleep initiation), hot flashes,
night sweats, cardiac disease, dysrhythmias,
red/orange, bitter/roasted, summer, south
Five Element Correspondences
 Earth

(Spleen, Stomach)
Nurturing, worry/obsession, GI issues
(loose stools, gastritis, bloating, abd pain),
sinusitis, cysts, tumors, lumps, dampness,
obesity, chronic fatigue (multifactorial),
sweet, dampness (cysts, edema),
yellow/brown, transitions of seasons,
center of compass positions
Five Element Correspondences
 Metal

(Lung, Large Intestine)
Respiratory, skin disorders (“3rd lung”),
constipation, dryness, sense of duty, grief,
loss, depression (multifactorial),
flavorful/spicy, white/grey/colorless, autumn,
west
Yin & Yang Deficiency & Excess
Yin Deficiency
Yang Deficiency
Yang will appear in Yin will appear in
excess with heat, excess with cold,
dryness, thirst,
fluid retention,
back pain, stiffness chills, back pain,
insomnia, loss of
daytime fatigue,
willpower to follow low libido, loss of
through with
willpower to
action. This is
initiate action.
Empty Heat
This is Empty
compared to Full
Cold (tonify
Heat (tonify rather
rather than
than disperse).
disperse).
Yang Excess
Yin Excess
Yang appears
in excess with
Full Heat –
migraines,
pressure,
bloating, mania,
hypertension,
anger,
insomnia, fever.
Full Heat
(disperse rather
than tonify).
Yin appears in
excess with Full
Cold – usually due
to Wind Cold
invasion. Stiffness,
contraction of
tendons, chilliness,
severe menstrual or
abdominal pain,
fluid retention and
watery-loose
discharges
including stools.
The Yo-Yo Rest-Stress Cycle
What to Do?

Whip the adrenals to give you more energy




Sustained use of hormones (cortisol, pregnenolone,
DHEA, thyroid) and other supplements
Some brief gain before reaching the cliff’s edge
(Bad Idea)
Alter your Lifestyle







Acknowledge stressors
Adequate sleep
Appropriate exercise
Nutritious diet
Moving meditation
Psychotherapy
Short term supplements
Relaxation Techniques
The Five Agreements
by Don Miguel Ruiz
1. Be Impeccable With Your Word.
2. Don't Take Anything Personally.
3. Don't Make Assumptions.
4. Always Do Your Best.
5. Be Skeptical, But Learn to Listen.
Relaxation Techniques
 Cognitive
Behavioral Therapy or other
Psychotherapy
 Moderate Graded Exercise
 Tai Chi
 Yoga
 Meditation
 Guided Imagery
Cognitive Behavioral Therapy


Form of psychotherapy – goal is to identify, modify and
change factors that may be maintaining symptoms
Individualized therapy to improve patterns


Rest, activity, sleep patterns, exercise capacity, cognition, coping
strategies, problem solving, reducing stress, anxiety and
depression
Well studied and effective in Chronic Fatigue Syndrome

Meta analysis reviewed 10,768 publications published on
interventions for chronic fatigue syndrome and selected 70 that
met the selection criteria
• Cognitive Behavioral Therapy had best evidence of best outcomes
• Moderate Graded Exercise was 2nd best evidence/outcomes
Chambers D et al. J R Soc Med. 2006;99:506-520


Improving fatigue symptoms and cortisol levels
Possible exception – very low morning cortisol may predict less
response to CBT
Psychotherapy

Professional burnout (exhaustion, fatigue,
feelings of reduced competence)
 14 sessions of psychotherapy
 Low morning cortisol prior to series of
treatments - increased after 14 sessions
Mommersteeg PM. Health Psychology. 2006;25(2): 243-248
Exercise

Moderate Graded Exercise

Exercise with moderate exertion that gradually increases in
intensity over 6-8 weeks
• Avoids over-exertion which causes post-exercise worsening of
fatigue condition

148 patients with Chronic Fatigue Syndrome randomized to
moderate graded exercise versus standard medical care
• Highly significant improvements in physical functioning, sleep,
fatigue, mood, and disability
Powell P et al. BMJ 2001; 322 : 387

Cochrane review of 9 randomized trials


Moderate graded exercise effective for fatigue
Better than prozac, though prozac plus exercise superior
Edmonds M et al. Cochrane Database of Systematic Reviews 2004, Issue 3
Tai Chi

Moving Meditation
 Equivalent to moderate physical exercise
(walking 6mph) and superior to sitting meditation
and neutral reading in 96 men and women

Reducing stress-induced elevations of urine
catecholamines (stress hormones), salivary cortisol,
pulse, and blood pressure
Jin P. J Psychosom Res. 1992;36(4);36-70
Tai Chi

After heart attack, Tai Chi more effective than moderate
exercise or support group in lowering diastolic BP
Channer KS et al. Postgrad Med J 1996; 72: 349-351

66 Tai Chi practitioners controlled for experience and
time of day. Pre and post…


Serum cortisol, norepinephrine, heart rate, Profile of Mood States, Trait
Anxiety Inventory
More experienced practitioners had higher pulse rates

Slowly learned skill which will result in more benefits with experience


Mood improved and remained elevated > 1 hour
Reduced tension, anger, fatigue, depression, confusion,
anxiety, cortisol, and norepinephrine

Tai Chi has low physical workload - 50% of VO2 max
Jin P. J Psychosom Res. 1989;33;197-206
Meditation

Sitting Meditation effective for relieving stress

Improves cortisol, pulse, blood pressure, total protein,
reaction time
Sudsuang R et al. Physiol Behav. 1991 Sep;50(3):543-8

Compassion meditation vs discussion group



Cortisol, IL-6, Profile of Mood States, Trier Social
Stress Test measured before and after
No group difference
Subset who meditated longer than the median had
significant improvements in IL-6, POMS, TSST but
not cortisol
Pace TWW et al. Psychoneuroendocrin 2009;24(1):87-88

Sitting Meditation not as effective as Tai Chi
Jin P. J Psychosom Res. 1992;36(4);36-70
Yoga
 Women
in 3-month yoga training versus
wait list controls

Improved perceived stress, State and Trait
Anxiety, well-being, vigor, fatigue, depression,
pain relief, salivary cortisol levels
Michalsen A et al. Med Sci Monit, 2005; 11(12): CR555-561
 Effective

in women with breast cancer
Fatigue, well-being, sleep, cortisol levels
Raghavendra RM J Clin Oncol 28:15s, 2010 (suppl; abstr 9099
Guided Imagery
 13
week program of Bonny Guided
Imagery and Music



Profile of Mood States test
Morning cortisol
Tests baseline, after 13 wks, & 6 months later
 Improved
mood, depression states, and
morning cortisol
McKinney CH. Health Psychology. 1997:16(4):390-40
Perspective

Moving Meditation

Tai Chi superior to Sitting Meditation for improving
stress response
Jin P. J Psychosom Res. 1992;36(4);36-70
• I assume a likely similar finding for yoga, but have not seen
comparison study.
• I assume that very active and rhythmic engagement of spine
and pelvis is the mechanism for this difference

Experience Grows

Tai Chi study
• More experienced practitioners had higher pulse
rates


Slowly learned skill which will result in more benefits with
experience
Jin P. J Psychosom Res. 1989;33;197-206
Meditation study
• Subset who meditated longer than the median had
significant improvements in stress response
Pace TWW et al. Psychoneuroendocrin 2009;24(1):87-88
A Few Cases
Case 1: Cortisol High, DHEA low





62yo F with fatigue for 5 months and feels cold,
sweaty all day. Chronic insomnia.
Major stressor: frequent interstate travel to care
for father with dementia in setting of lack of
support by local sibling and intermittent sibling
conflict
Low basal body temp 97.3-97.7. Long flu-like
illness 1 month earlier complicated her fatigue
Acupuncture and (Chinese Herbal) Minor
Bupleurum started for 4-6 weeks, labs drawn.
TSH 1.56, Free T3 2.9, Free T4 1.37, RT3 30,
normal CBC and Chem 7
Case 1: Cortisol High, DHEA low
Adrenocortex Stress Profile
(saliva sampling x 4 in one day)
Case 1: Treatment Plan



Encourage adequate rest and sleep
Meditation training referral
Acupuncture






Tonify Kidney Yin and settle Heart Shen
CorticoB5B6 (Vit C 250mg, B6 100mg,
pantothenic acid 500mg, magnesium 75mg,
citrus bioflavanoid complex 100mg) 1 tablet
three times per day
L-Theanine 200mg twice per day
GABA 700mg daily in morning
DHEA 25mg daily in morning
Rescue Formula 3 twice per day (TCM: Heart
Shen disturbance)
Case 1: Follow-Up





Over the next 3 weeks, GABA increased
gradually to 1400mg twice per day and
L-theanine increased to 400mg in AM, 200mg in
PM
Ambien stopped.
By week 5-6, Fatigue 75% better, insomnia
improving intermittently with no ambien
Eventually had to use intermittent lower dose
Ambien but able to remain of nightly higher dose
Case 2: Cortisol Low

71yo male with 1 year of worsening profound
fatigue. Previously athletic. Now so tired that
“the other day I didn’t have the energy to read
the newspaper.”
 Stressors: stressful years in business, divorce,
two decades of simple carb diet, prostate cancer
5 years ago, major stress including extensive
and prolonged anger 4-5 years ago, low
testosterone
 Other: low back pain, dry mouth, tendency to
anger when stressed
 Exam: horizontal creases in fingerprints, thinning
hair and eyebrows, pitted nails, normal
heart/lung/abdomen exam.
Case 2: Cortisol Low, DHEA norm
Adrenal Fatigue – Induced
Connective Tissue Dysfunction?
Creased Fingerprints
Suggests deficiency Connective
Tissue integrity – often improves
with resolution of fatigue
Ridged Fingernails
Case 2 - Considerably worse than
this until 2 months into treatment
Adrenocortex Stress Profile
(saliva sampling x 4 in one day)
Case 2: Treatment Plan

Acupuncture weekly









Kidney Yin, Ming Men tonified (10 treatments over 3 months)
Meditation – “too time consuming”
Encourage rest when needed and adequate sleep
Chinese Medicine (Kidney Yin Deficiency)
Nourish the Root 4 tablets at bedtime
Gut mucosal and digestive/absorption support:
Glutagenics ( L-glutamine 3 grams, DGL 200mg, Aloe
50mg per tsp) 1 teaspoon twice per day
Bio-Gest (Betaine HCl, Ox Bile concentrate, pancreatic
enzymes) 2-4 capsules with each meal.
Ultra Flora Plus DF Capsules (Lactobacillus species and
Bifidobacteria 15 billion colonies per capsule) 2/day
Case 2: Treatment Plan







Adrenal Support:
Adreset (1 tablet: cordyceps 400mg, panax ginseng 200mg, rhodiola
50mg) 1 tablet three times per day
CorticoB5B6 (1 tablet: Vit C 250mg, B6 100mg, pantothenic acid
500mg, magnesium 75mg, citrus bioflavanoid complex 100mg)
1 tablet three times per day
Pregnenolone (1 capsule: 30mg) 1 capsule in morning and
afternoon no later than 2pm
EPA-DHA 720 (Fish Oil with EPA 430mg, DHA 290mg per gelcap) 2
twice per day
Collagen JS (Pure Encapsulations- Hydrolyzed type II collagen
complex from chicken sternal cartilege 500mg/capsule) 4 capsules
per day with meals and 8oz water
Adrenal Rebuilder (porcine adrenal, gonad, hypothalamus and
pituitary concentrates processed to remove hormones) 1 pill three
times per day for one week and then increase to 2 three times per
day on week 2
Case 2: Follow-Up

4 weeks: 85-90% improved compared to 2 years prior.
Beginning to exercise
 6 weeks: 95% improved. Leg pressed 400lbs 12
repetitions/set for 6 sets at age 72.
 3 months: 100% resolved to normal energy. Blood
pressure high in 150s for 1st time. Stopped Adreset,
Collagen, Pregenonlone, and Biogest
 5 months: Blood pressure normal, Fatigue still resolved.
Hair and eyebrows thick and bushy after prior thinning.
Pitted/ridged fingernails normalized. All supplements
stopped.
 7 months to 1 year later: Added testosterone in face of
history of prostate cancer with close PSA monitoring.
Athletic. No fatigue. Vibrant
Risks of Treatment of
“Adrenal Fatigue”

Expense (short term but significant)
 High Blood Pressure


Insomnia


Resolved by lowering DHEA, pregnenolone, glandular
Resolved by lowering DHEA, pregnenolone, glandular
DHEA impairs function of Tamoxifen (used in ER
positive breast cancer) when level of
DHEA-Sulfate > 90
 Failure to recognize other causes of fatigue
Case 3:
Cortisol & DHEA Normal, Glucose High

38 yo M - fasting glucose 106 with no diabetes
risk factors, excellent nutrition, strong family
history of early heart disease.
 Normal blood pressure, BMI 21.5. Tendency to
irritability, some fatigue if not rested, back ache,
easily chilled, frequent viral infections
 Stressors: demanding career,
family commitments,
inadequate sleep due to work
and variety of outside interests
Case 3:
Cortisol Normal, Glucose High
Adrenocortex Stress Profile
- Case 3 –
Cortisol Normal, Glucose High
Glucometer for Fasting Blood Glucose over 2 ½ months
Best predictor for elevated fasting BG in this case:
Inadequate Sleep and 2-3 consecutive work days
4 months,
1 year,
2 years out
Glucometer with “lifestyle diary” as Biofeedback
Case 3: Treatment Plan

Promote adequate rest, Tai Chi, yoga,
meditation, exercise, counseling referral
 Acupuncture weekly x 5-8 weeks


Alternate Liver Qi movement, Kidney Tonification
Chinese herbs for Kidney Yang Deficiency


Dynamic Warrior 60 drops/day in AM
Warmth
• Keep warm while exercising
• Eat warming foods (teas, garlic, ginger, steamed vegetables
vs. raw)
• Avoid cold foods (ice, cool liquids, minimize raw veg)
Case 4:
Perimenopausal Anovulation

42 yo female, normal BMI 24, exercises, fit
 Mild autoimmune hypothryoidism 2005
 History suggestive of mild Adrenal stress

4/2010 low secretory IgA, salivary cortisol mildly low in AM (rest
of day normal). Normal fasting insulin and 17-OH progesterone
• Secretory IgA low levels strongly correlate with daily stress, loss of
sense of humor, negative emotions, anger/irritability
Martin RA. Int J Psychiatry Med 1998;18:93-105.

Rein G. J Adv Med 1995;8:87-105
Fatigue responsive to adrenal support supplements in
Summer 2010, but increased androgenic effect (mild
facial hair) - Supplements stopped 9/2010

Fatigue partially returned, then better with change from
sustained release T3/T4 to Armour Thyroid (low dose 15mg)
Case 4:
Perimenopausal Anovulation

Missed menstrual period 9/2010



Self-corrected – menstruation 10/2010
Single ovarian cyst found on ultrasound 10/2010 (not
polycystic)
Spring 2011 - Missed menstrual period 60+ days
 Abdominal bloating/discomfort, fatigue, hot
flashes
 Family history of early menopause
 Question: Is this perimenopause? Is thyroid
dose correct? Time for hormones? Which?
Urine Pregnancy Negative
Thyroid normal TSH 1.97, FT4 0.93, FT3 2.9
Luteinizing Hormone 55.9 u/L (0.8-15.5)
Follicle Stim Horm 30.7 u/L (1.4-9.6)
Progesterone 1.5 ng/ml (1.4-16.6) 1.5mcg/L
Estradiol 129 pg/ml (19-157)
0.129mcg/L
Because FSH is only 30 and is
about half LH, this is not
menopause yet (would be very
high FSH)
With Progesterone very low,
Estradiol modest, and LH high,
this is “anovulation”.
Treatment: Progesterone x 7-10 d
Ovulation triggered by LH Surge. If
this is not high enough or is
gradual or poorly timed, then
ovulation cannot occur. Can
stress play a role?
Hypothalamus - Pituitary – Ovary
(Stress and the “LH Surge”)

Ovulation requires correct timing and level of
Luteinizing Hormone (from pituitary)



“LH Surge”
Pulsing too late, too slowly, or ill timed – no ovulation
No ovulation > no corpus luteum > low progesterone

LH Surge requires very specific pulsations of
Gonadotropin Releasing Hormone by the
hypothalamus
 Can stress influence LH surge?

Could influencing any stress effect help alleviate
perimenopausal symptoms?
Stress and Anovulation

Administering Corticotropin Releasing Hormone (CRH) inhibits
release of Gonadotropin Releasing Hormone (GnRH) at the
Hypothalamus


Stress causes ineffective pulsation of the “LH Surge”
Hypothalamic amenorrhea

Stress-induced loss of periods
• Extensive exercise in young athletes with low body fat

High cortisol, High ACTH
• Consistent with chronic stress response

Low LH, FSH, estradiol, allopregnanolone
• Don’t have periods and don’t have enough estrogen to build lining

Much less responsive to CRH given experimentally and already prone
to lower CRH due to persistently high cortisol (stress)
Meczekalski B et al. European Journal of Endocrinology 2000;142:280–285

East German war refugees low cortisol, high LH compared to normal
Bauer M et al. Psychiatry Research 1993;5 I:75435

Stress-induced high cortisol, high ACTH, and high CRH all cause
pituitary to release a weak LH surge in sheep, cows
Breen KM et al. Endocrinology 148(4):1882–1890
Stoebel DP et al. J Dairy Sci 1982;65:1016-1024
Stress and Perimenopause

Can stress influence LH surge?


Is it possible to reverse the chronic stress
response and normalize cortisol and CRH?


Yes
Could influencing any stress effect help alleviate
perimenopausal symptoms?


Yes
Probably, and with other positive health benefits
Other considerations


Luteal phase progesterone supplementation to
facilitate menstruation
Due to development of facial hair (androgen effect)
• Adaptogens instead of glandulars, pregnenolone, DHEA
• **Elevated LH also increases androgen production
Case 4 - Treatment Plan
Induce menses with “progesterone withdrawal”
(7-10 days progesterone – period 2 days later)
 Self-examine lifestyle



Adequate sleep (use relaxants if needed), negative
vs. positive emotions, regular moving meditation (Tai
Chi or yoga), B-vitamins, fish oil, magnesium,
consider adaptogens, acupuncture
Consider hormones


(Testing is useful)
Test menstrual cycle hormone levels (3 day interval)
Likely to benefit from additional bioidentical
progesterone
• Oral if planning to use salivary sampling (topical hormones
concentrate in saliva, making followup salivary test useless)

Birth control pill would help but not likely necessary
• Avoid blood clot risk by avoiding estrogens if not indicated
Polycystic Ovary Syndrome
Lumpkin M. The Hypothyalamic Pituitary Adrenal Axis. Textbook of Functional Medicine.
Ed. Jones D. Institute for Functional Medicine. 2005
Supplements
Carrot or Stick? Depends on Use.
Perspective

There are very few good human studies on the
use of supplements for fatigue/stress
 There are NO long-term supplement studies in
fatigue
 There are numerous studies on Tai Chi, Yoga,
Meditation, Exercise, Psychotherapy, Sleep
 I prescribe supplements with the intention to use
them for 2-6 months


Goal: Help restore improved function and less fatigue
in order to begin and maintain lifestyle changes that
are critical to reversing the HPA axis dysfunction
Primarily based on clinical experience, some
mechanism research
Chronic Fatigue Syndrome
- treatment review Chambers D et al. J R Soc Med. 2006;99:506-520

Meta analysis reviewed 10,768 publications published on
interventions for chronic fatigue syndrome and selected
70 that met the selection criteria
Graded evidence and success of
several treatments in order
Others deserving mention
1.Cognitive Behavioral Therapy
DHEA
2. Graded exercise program
Acetyl-L-carnitine and propionylL-carnitine
3. Inosine pranobex
EPA-DHA (fish oil)
4. Low dose hydrocortisone
Magnesium
Supplement Categories

Adrenal Adaptogens
 Nutrients





B-vitamins
Magnesium
EPA-DHA (fish oil)
Collagen
Relaxants
 Hormones
 Glandulars
Adrenal Adaptogens

Term coined by Russian Lazarev in 1947 and
modified by Brekhman in 1960s





1) Harmless to host
2) Nonspecific, general effect
3) Increases resistance to stressors (physical,
chemical or biological)
4) Acts as stabilizer/normalizer
Examples

Rhodiola, Panax ginseng, american ginseng,
ashwaghanda, holy basil
Adaptogens - Rhodiola

Slows degradation of serotonin, dopamine, NE
 Prevent catecholamine release & activity in heart muscle
 Prevent catecholamine depletion in adrenal
Stancheva SL. Med Physiol 1987;40:85-87
Maslova LV et al. Eksp Klin Farmakol 1994;57:61-63

60 subjects with fatigue randomized; rhodiola vs placebo


Improved concentration, decreased stress-related fatigue,
improved cortisol
Olsson EM et al. Planta Med 2009;75:105-112
Anxiety improved in RCT of rhodiola use
Bystritsky A et al. J Altern Complement Med 2008;14:175-180

Physicians in residency (sleep deprivation, night duty)

Reduced fatigue, improved mental performance
Darbinyan V et al. Phyotmedicine 2000;7:365-71
Other Adaptogens

Ashwagandha




(Ayruvedic Medicine)
Animal studies show anti-stress, anti-depressant,
anxiolytic, anti-inflammatory, antioxidant, immune
function improvement effects
No large human studies
Does not cause high blood pressure, water retention
or insomnia sometimes seen in prolonged high dose
ginseng use
Holy Basil (Ayruvedic Medicine)


Reduces blood glucose in clinical trial of Type 2
Diabetics
Animal studies: Stabilizes response to stress, immune
modulation, liver protective, reduces stomach ulcers
Other Adaptogens

Ginseng (Panax, American, Siberian) (Chinese Med)

Animal research suggests that the ginsengs produce
stress modulation effects opposite the current cortisol
status
• Low cortisol – HPA-axis stimulation
• High cortisol – HPA-axis relaxation

I recommend Panax or American but not Siberian (too
excitatory/warm)
Gaffney BT et al. Life Sci 2001;70:431-442

Cordyceps

(Chinese Medicine)
Extensively used in Chinese Medicine for
fatigue/vitality, immune dysfunction, and asthma or
other causes of lung dysfunction
Nutrients: Adrenal, CNS and GI

B vitamins and Magnesium
• Important co-factors for many reactions in synthesis of
neurotransmitters. Well documented calming qualities.

EPA-DHA (fish oil)

Reduces inflammation, depression, improves lean
muscle mass, lowers epinephrine and norepinephrine
release in stress response, lower all-cause mortality
Chromium – insulin sensitivity, depression, lipids
 Collagen – chicken sternum – for poor
connective tissue in setting of fatigue
 GI – probiotics, glutagenics

B-vitamins

B1 – Riboflavin



Reduces post-operative stress response
120mg injected daily for several days pre-surgery
reduced cortisol spike during and immediately
following surgery
Continued use for days prevented usual postoperative rebound cortisol drop
Vinowgradov VV et al. Probl Endokrinol 1981;27:11-16

B3 – Niacinamide


High dose (used for lipid treatment) increases REM
sleep in normal sleepers, and helpful for insomnia
Mechanism: Tryptophan levels likely increased
• Negative feedback on tryptophan pyrrolase (trypt > niacin)
• Pushes tryptophan into making 5HTP and then to serotonin
• Vitamin B6 is important co-factor
Robinson CR et al. Biol Psyhiatry 1977;12:139-43
B-vitamins

B5 Pantothenic Acid


Enhances function of adrenal cortex
Also down-regulates adrenal response in times of high stress
• Blunts response to infused ACTH
• Adrenal response to Vit B5 depends on current adrenal function

B6 Pyridoxal-5-Phosphate (P5P – active form of Vit B6)


Essential cofactor for synthesis of serotonin, dopamine and
GABA
Conversion of tryptophan to 5HTP is the “rate-limiting step for
the creation of serotonin
• Inhibited by stress, P5P deficiency, insulin resistance, Mag def

B12 Methylcobalamin


Combines with bright light exposure to reset circadian cortisol
rhythm (up in AM, low in PM)
Folate

Required for synthesis of BH4 (tetrahydrobiopterin) which is
essential for creation of serotonin, dopamine, epi, & NE
Relaxants

L-Theanine (Green Tea is common source – blunts caffeine effect)


Increases serotonin, dopamine, glycine
Increases alpha-wave activity in brain
• Calming, more alert, lower pulse rate with stressors
Yokogoshi H. Neurochem Res 1998;23:667-73. Yamada T. Amino Acids 2009;36:21-37
Ito K. Nippon Nogeikagaku Kaishi 1998;72:153-7 Kimura K. Biol Psychol 2007;74:39-45

GABA – gamma-Aminobutyric acid – inhibitory
neurotransmitter
 GABA receptor bound by benzodiazepines and sleep
aids (calming effect)
 Reduces stress response, anxiety/panic, insomnia
Abdou AM Biofactors 2006;26:201-8
Green ML Biofeedback Self Regul 1988;13:187-99
Relaxants

L-tryptophan / 5-HTP (5-hydroxytryptophan)


Precursor to serotonin. As effective as tricyclics for depression.
Improves Premenstrual mood swings.
Improves sleep onset and quality.
Richard DM. Int J Tryptophan Res. 2009 March 23; 2: 45–60

Does not limit cognitive performance or inhibit arousal from sleep
Lieberman HR. Am J Clin Nutr 1985;42:366-70

5HTP 2mg/kg effective for childhood night terrors
Bruni O et al. Eur J Pediatr 2004;163:402-7

Bacopa

(Ayruvedic Medicine)
Effective for anxiety and cognitive function in randomized trials
Singh RH et al. J Res Ayru Siddha1980;1:133-148
Stough C. Psychopharmacology 2001;156:481-84
Calabrese C. Altern Complement Med 2008;14:707-13
Relaxants

L-Tyrosine




Precursor to catecholamines (dopamine, epinephrine,
norepinephrine)
Helps prevent stress-induced depletion of
catecholamines
Improved performance in stressful situations
Melatonin



Well documented efficacy for insomnia and jet lag
Can cause dream disturbed sleep
Can inhibit arousal from sleep (sleep hangover effect)
Hormones

A word to the wise….

Use as little dose (per day and over time) as
necessary




Avoid very long periods (>6 months) if possible
Accept the risks if outweighed by benefits
Try intermittent downward tapers of hormones
If low hormones are replaced, the rest of the
Endocrine System will respond/adjust



Very complex system
Screen for prostate/breast cancer
Remember the Carrot/Whip metaphor
Glandular Hormones




Animal endocrine organs purified/extracted/dried
Common example of standardized glandular is Armour Thyroid
Literature review dominated by 1930-1940s – no current scientific
articles on medicinal use of adrenal glandular
Adrenal cortical extract



Injected into children, studied blood chemistry and immunological
effects
Increased cholesterol, tendency toward lower glucose level.
Normal CBC, sedimentation rate, total protein and pertussis titres – no
change
Kelley VC, Adams JM. J Peds 1948;32(3):282-287

My anecdotal clinical experience



Equivalent to a low dose of cortisol, frequently helpful for fatigue
Adverse: Can cause over-stimulation of the HPA Axis – increased
cortisol, insomnia, high blood pressure, “wired” effect
Two concerns: 1) prolonged use (>6 months) 2) contaminants from
food chain
Hormones
 Pregnenolone


Modulates NMDA and GABA receptors
Use – in setting of low cortisol with fatigue
• Short term 2-3 months for symptomatic relief.
Increase exercise, rest, relaxation, adaptogens

Adverse – increased androgens (hair growth,
acne, irritability), insomnia, palpitations
– previously discussed
 No long-term studies
 Progesterone
Hormones - DHEA

Effective in major and non-major depression in men and
women
Wolkowitz OM et al. Am J Psychiatry.1999;156:646-649
Rabkin JG. Am J Psychiatry. 1996;163:59-66
Schmidt. Arch Gen Psychiatry. 2005;62:154-162


Improves concentration, libido and fatigue in small
studies of Chronic Fatigue Syndrome and Lupus
Adverse effects



Facial hair, acne, irritability, elevated BP, insomnia, reduces
efficacy of tamoxifen if DHEA-S levels >90
Theoretical fear of amplifying breast/ovarian/prostate cancer due
to conversion to estrogen and testosterone – clinical exam and
lab screening
No long term studies to establish safety of long term use
Hormones - Cortisol

5-10mg/day for 1 month effective for CFS
without psychological diagnosis


Physiologic dosing equivalent
Reduced fatigue without affecting endogenous
adrenal function
Cleare AJ et al. Lancet 1999; 353(9151):455 – 458

Well established in Adrenal Insufficiency


Failure to double cortisol level with ACTH 250mcg
No long-term studies other than Adren Insuff
Supplements
I
select supplements based either on
testing or on questionnaire-based protocol

Adrenocortex Stress Profile
• Salivary Cortisol at 7AM, 10AM, 4PM, 11PM
• Salivary DHEA at 7AM
• Some tests include 17-OH Progesterone


More objective rationale for use of progesterone,
however clinical observation is as useful
Thyroid studies, CBC, Chem 14
• Make sure no thyroid, hematologic, kidney, liver dz

Metagenics Stress IdentiT protocol
Summary



Chronic, persistent stress is harmful & feels bad
Restful, uninterrupted sleep is essential
Loosen Attachment to Destructive Emotions





Anger, worry, anxiety, irritability
Psychological counseling important
Promote positive outlook
Tai Chi, Yoga, Moderate Exercise, Meditation
Supplements can play a role for short term



2-6 months
Not likely good to use on a chronic, continuous basis
Used to improve quality of life and well-being long
enough to take advantage of lifestyle changes
The Five Agreements
by Don Miguel Ruiz
1. Be Impeccable With Your Word.
2. Don't Take Anything Personally.
3. Don't Make Assumptions.
4. Always Do Your Best.
5. Be Skeptical, But Learn to Listen.
www.drtomsalchemy.com
Stress, Fatigue
and
The Adrenals
Tom Archie, MD
St Luke’s Wood River
Family Medicine