CFS/ME and Adrenal Problems
Might Low Cortisol Be Causing Some of Your Symptoms?
Cortisol is a steroid hormone produced by our adrenal glands which is very important to our stress response. All stress - not just things we normally associate with the word "stress" such as being overloaded with work, but also anything from heat to infections - increases the production of cortisol.
Elevated cortisol levels may cause some or all of the health problems associated with stress. But having too little cortisol, adrenal insufficiency, is similarly problematic, as without sufficient cortisol our bodies can not properly handle stress.
Types of Adrenal Insufficiency
Addison's disease, an autoimmune illness, requires life-long treatment with hydrocortisone (the synthetic equivalent of cortisol). Even then a sudden lack of cortisol can provoke an Addisonian crisis, a medical emergency. Most cases of adrenal insufficiency are not life-threatening, but still produce bothersome symptoms.
There are two types of adrenal insufficiency: primary and secondary. In the former the problem lies in the adrenal gland, as in Addison's disease. In secondary adrenal insufficiency the brain does not produce enough of the hormones (ACTH and CRH) needed to stimulate the secretion of cortisol, or the body does not respond adequately to them. This is sometimes referred to as dysfunction of the HPA (hypothalamus-pituitary-adrenal) axis.
Adrenals and CFS/ME
The symptoms associated with adrenal insufficiency bear striking resemblance to the symptoms of CFS/ME: fatigue, lethargy, muscle and joint pain, low blood pressure/orthostatic hypotension, hypoglycemia (low blood sugar), headaches, fever, cold and heat intolerance, nausea, anxiety and poor sleep.
The similarity of the symptoms is probably not just a coincidence. Many papers have reported lower cortisol levels in people with CFS/ME, thought to be caused by secondary adrenal insufficiency. One study found that the adrenals of people with CFS/ME had actually shrunk by up to 50%.
When adrenal insufficiency is suspected, a doctor usually orders a blood test for cortisol levels. In Addison's disease the levels tend to be very low, but in secondary insufficiency they may show up within the normal limits. There is no clear consensus as which one is the best test for diagnosing low-level adrenal insufficiency, but saliva testing is often recommended.
Treatment
If a person with CFS/ME is found or suspected to have adrenal insufficiency, treatment with hydrocortisone should be considered. Multiple studies have evaluated this therapy and most of them have concluded that hydrocortisone can be beneficial in CFS/ME.
The dosage of hydrocortisone is usually 5-25 mg a day, taken in 1-3 doses. It is recommended to increase the dose in case of infections, heat and vigorous activity. In case of surgery the dose may need be greatly increased, up to more than 100 mg.
Most people with CFS/ME, even those who are sensitive to medications, tolerate hydrocortisone without problems. Some may find that they do better with other steroids, like prednisone or dexamethasone. Licorice root can also be helpful, because it slows the breakdown of cortisol in the body.
People are often averse to the idea of steroid therapy, but low doses of hydrocortisone do not have the risks of high-dose steroid therapy, such as immunosuppression, osteoporosis and weight gain. Low dose hydrocortisone is simply replacement therapy, like insulin for diabetics or thyroxine supplementation for hypothyroidism.
References
Scott LV, Teh J, Reznek R, et al. Small adrenal glands in chronic fatigue syndrome: a preliminary computer tomography study. Psychoneuroendocrinology. 1999 Oct;24(7):759-68.
Holtorf Ken. Diagnosis and Treatment of Hypothalamic-Pituitary-Adrenal (HPA) Axis Dysfunction in Patients with Chronic Fatigue Syndrome (CFS) and Fibromyalgia (FM). J Chron Fatigue Syn. 2007;14(3):59-88.
