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Yesterday afternoon, I was working to finish a newsletter that contained an article I've written on thyroid antibodies. I knew that many of our readers would find the topic interesting and helpful. But then something happened that abruptly stopped the press. A friend sent me a copy of Dr. Peter Hibberd's latest newsletter.

Hibberd's newsletter contains an inquiry from someone named Jim Z: "Please explain," Jim asks Dr. Hibberd, "what causes adrenal fatigue, how to treat it, and how long it takes to recover." When I read Dr. Hibberd's answer, I put away the antibody article and wrote this response to his answer to Jim. Below, I address each part of Hibberd's one paragraph answer.

Terms Physicians Use. In answering Jim, Dr. Hibberd first wrote, "Adrenal fatigue is not a term physicians use." This statement is less important than the others Hibberd made, but as it is categorically false, it needs correcting.

Dr. James Wilson, author of Adrenal Fatigue,[7] is a PhD, and he's also a chiropractic and naturopathic physician. If no other physician in the world uses the term adrenal fatigue, Dr. Wilson certainly does, and that fact alone refutes Hibberd's absolutistic pronouncement. Hibberd, of course, may not consider chiropractic and naturopathic doctors physicians. (Labs and insurance companies classify them as physicians, and many states in the U.S. license them as such. But this is a quibble, so I'll move on.)

Even if Hibberd doesn't consider Dr. Wilson a physician, Hibberd's statement is still patently false. I've attended lectures by Dr. Wilson on adrenal fatigue in which he addressed audiences of up to 700 clinicians; most of them were MDs and DOs. Also, Dr. Wilson often lectures across the nation to other groups of physicians. And he isn't the only physician who teaches other physicians to diagnose and treat adrenal fatigue. The total number of physicians who have studied under Dr. Wilson and other believers-in-adrenal-fatigue is assuredly large, and I'm confident that most of them do use the term adrenal fatigue. I've personally talked with scores of physicians specifically about the disorder, and we all have conversed using the term Dr. Hibberd denies physicians use.

Many conventional physicians, including endocrinologists, often discuss health problems related to low levels of cortisol. It's true that when they do, most use older terms such as "hypoadrenalism," "adrenal hypofunction," and most often, "adrenal insufficiency." These terms, of course, are only synonyms for the newer term, "adrenal fatigue." But as you'll see, Dr. Hibberd even questions the existence of what conventional physicians call adrenal insufficiency.

Symptoms from Low Cortisol. Dr. Hibberd went on to say to Jim, "It [adrenal fatigue] is popular with alternative medical publications and is used to describe vague symptoms of fatigue, irritability, and body aches allegedly arising from adrenal insufficiency." (Italics mine.)

Here, Hibberd appears to question that such symptoms arise from adrenal insufficiency. I say this because he refers to the association between the symptoms and adrenal insufficiency as alleged. This means, of course, that alternative clinicians assert the association between the symptoms and the disorder with no proof of it.

Some clinicians do use the term adrenal fatigue to refer to patterns of symptoms. I certainly do. I do so because it's well documented that patients with too little adrenal production of cortisol experience the symptoms. Descriptions of the symptoms extend back at least 100 years in medical textbooks. Today, one can quickly find descriptions of the same symptoms through search engines on the Internet and at PubMed. Hibberd can also go to any medical library, and there, he'll find scores of recent textbooks on diagnosis that describe these same symptoms "arising from 'adrenal insufficiency.'" Many such books describe the symptoms of different degrees of adrenal insufficiency. They describe the symptoms of severe adrenal insufficiency including the potentially-deadly shock of adrenal crisis. But they also describe milder symptoms from less severe cortisol deficiencies. After Taber's Medical Dictionary,[5,p.40] we can refer to the latter as "relative" adrenal insufficiency, meaning relative to reference-range levels of cortisol.

As any other physician does, Dr. Hibberd needs to learn the symptoms of adrenal fatigue, adrenal insufficiency, or whatever one prefers to call it. He can do so within less than five minutes by Googling the two terms "adrenal insufficiency and symptoms." A huge number of medically-related websites will come up. When I did this a few minutes ago, Google gave me a count of sites that contain the two terms. The number was 251,000. When I typed in "symptoms and adrenal fatigue," Google indicated that 218,000 websites contain the terms.

When I used "adrenal fatigue" as the search term in PubMed, 919 abstracts of published papers came up. And when I used "adrenal insufficiency" as the search term, the number of abstracts that came up was 11,980. That's a lot of publications about a medical disorder that supposedly doesn't exist. Hundreds of the papers indexed in PubMed—far too many to reference here—resoundingly refute Hibberd's claim that ". . . tests used to define a decrease in adrenal function known [sic] do not support the existence of the condition.

The first paper indexed by PubMed that mentions adrenal insufficiency is dated 1922. It was published in the Journal of Physiology.[14] Its title is, "On the concentration of the blood and the effects of histamine in adrenal insufficiency." Hibberd implies that the term adrenal insufficiency is used only in "alternative medicine publications." The Journal of Physiology, however, is not an alternative medicine publication. Nor are scores of other journals that have published hundreds of papers on the condition Hibberd calls "allegedly" adrenal insufficiency. Consider one, the French medical journal La Presse Medicale. In 1953, it published a paper[6] about a symptom Hibberd seems to doubt can result from adrenal fatigue. The paper's title is, "Fatigue; a functional adrenal insufficiency syndrome." Hibberd can easily confirm that La Presse Medicale is far from an alternative publication; it's about as conventional as medical journals get.

Learning through Personal Experience. For some physicians, published scientific evidence is not good enough. They believe only what they themselves personally experience. If this is true for Dr. Hibberd, I suggest that he test through personal experience whether or not symptoms result from adrenal insufficiency. He can do this by undergoing a modified metyrapone test.

Metyrapone has long been used by endocrinologists to diagnose the adrenal condition that Hibberd denies exists. Diagnosticians even use the drug to differentiate between two well-known forms of adrenal insufficiency.[3][4] The drug lowers cortisol levels by preventing the last step in the production of cortisol. It does so by blocking the enzyme 11beta-hydroxylase that triggers the conversion of 11-deoxycortisol to cortisol.[4,pp.278-9]

I challenge Dr. Hibberd to use metyrapone to lower his cortisol level by, say, 40%, and keep it there for a week while he works the most demanding hours in the ER. If he then comes back and tells us with a straight face that symptoms such as fatigue don't develop from low cortisol levels (as in adrenal fatigue), I may start to doubt my own sanity. Instead, though, I'm confident that he'll come back a physician newly enlightened about the fact of adrenal fatigue.

But taking the drug metyrapone isn't the only way to induce adrenal insufficiency. Stress can also do it, as Dr. Wilson explains so well.[7] In fact, stress is basic to the concept of adrenal fatigue. Studies have shown that patients who have had chronic stress, sometimes resulting in post-traumatic-stress-disorder, have low urinary and blood cortisol levels.[8][9] In one study, the more combat experience veterans had, the lower their blood levels of cortisol.[10] Researchers found that women with chronic pelvic pain had lower blood and saliva levels of cortisol. The researchers conjectured that the women's pain resulted from too little protective cortisol. They reported that  the women's low cortisol was associated with more abusive experiences and a higher number of "major life events."[11] And low cortisol levels have followed the stress of recent myocardial infarctions.[12]

Conclusions. Dr. Hibberd concluded: "Be careful accepting diagnostic labels from an unqualified individual. Instead, consult your personal physician for [sic] correct diagnosis. Your recovery time will depend upon treatment options provided once your real diagnosis has been established."

When it comes to diagnosing and treating the well-documented disorder of adrenal insufficiency, who is the "unqualified individual" (to use Hibberd's term)? In my opinion, one such person is the clinician who is unaware that the disorder exists. This clinician is not likely to order tests that can verify that the disorder is the cause of a patient's symptoms. In that case, the patient's "recovery time" (to use another of Hibberd's terms) will be delayed until he finds another clinician who'll accurately diagnose the disorder and properly treat the patient for it.

Unfortunately, the delay can compound the patient's woes. Consider, for example, the patient with antibodies against the cortex of his adrenal glands. These can cause the form of adrenal insufficiency called "Addison's disease." Classic symptoms of the disorder are weakness and fatigue that clinicians used to call "asthenia." The antibodies lower cortisol levels by destroying an enzyme, 12-hydroxylase, that converts a form of progesterone to cortisol. If a physician is aware that low cortisol could be the cause of his patient's fatigue, he's likely to order appropriate tests. These can confirm both the low cortisol and the autoimmune process. With proper treatment, the cost to the patient's health can be limited to the fatigue he suffered before proper treatment began.

But consider what can happen if the physician falsely believes that low cortisol from adrenal insufficiency doesn't occur and doesn't cause fatigue. He may fail to confirm through testing the cause of the patient's fatigue. Then, as precious time passes, the inflammatory process in the patient's adrenal glands may progress, and he may end up with widespread destruction of the cortex of the glands. This will result in deficiencies of other hormones in addition to cortisol.[13] In this happens, the cost to the patient's health will far exceed his experience of fatigue.

To believe that adrenal insufficiency doesn't exist is about like believing there is no such condition called anemia. The fact is, Dr. Hibberd is as likely to encounter patients with adrenal fatigue as he is those with anemia. I trust that he wants to serve all his patients well. So that he can—including those with adrenal fatigue—I urge him to correct his false beliefs about the disorder (even if he refuses to call it by the new term), and to learn how to diagnose and treat it so he can help those countless people whose symptoms are caused by it.

References

1. Ask Dr. Hibberd: NewsMax.com, 4152 West Blue Heron Blvd, Ste 1114, Riviera Beach, FL, 33404 USA, April 08, 2009.
2. Dolman, L.I., Nolan, G., and Jubiz, W.: Metyrapone test with adrenocorticotrophic levels. Separating primary from secondary adrenal insufficiency. JAMA, 241(12):1251-1253, 1979.
3. Berneis et al.: Combined Stimulation of Adrenocorticotropin and Compound-S by Single Dose Metyrapone Test as an Outpatient Procedure to Assess Hypothalamic-Pituitary-Adrenal Function. J. Clin. Endocrinol. Metab., 87:5470-5475, 2002.
4. Stobo, J.D., Hellmann, D.B., Ladenson, P.W., et al.: The Principles and Practice of Medicine, 23 edition. New York, McGraw-Hill Professional, 1996.
5. Taber's Cyclopedic Medical Dictionary. Edited by C.L. Thomas. Philadelphia, F.A. Davis Co., 1985.
6. Rivoire, M.R., Rivoire, J., and Poujol, M.J.: Fatigue; a functional adrenal insufficiency syndrome. Presse Med., 61(70):1431-1433, 1953.
7. Wilson, J.L.: Adrenal Fatigue: The 21st Century Stress Syndrome. Petaluma, Smart Publications, 2005.
8. Yehuda, R.: Biology of posttraumatic stress disorder. J. Clin. Psychiatry, Suppl 17:41-46, 2001.
9. Kanter, E.D., Wilkinson, C.W., Radant, A.D., et al.: Glucocorticoid feedback sensitivity and adrenocortical responsiveness in posttraumatic stress disorder. Biol. Psychiatry, 50(4):238-245, 2001.
10. Boscarino, J.A.: Posttraumatic stress disorder, exposure to combat, and lower plasma cortisol among Vietnam veterans: findings and clinical implications. J. Consult. Clin. Psychol., 64(1):191-201, 1996.
11. Heim, C., Ehlert, U., Hanker, J.P., et al.: Abuse-related posttraumatic stress disorder and alterations of the hypothalamic-pituitary-adrenal axis in women with chronic pelvic pain. Psychosom. Med., 60(3):309-318, 1998.
12. Ceremuzyński, L., Kuch, J., Markiewicz, L., et al.: Patterns of endocrine reactivity in patients with recent myocardial infarction. Clinical and biochemical correlations: trial of endocrine therapy. Br. Heart J., 32(5):603-610, 1970.
13. Winqvist, O., Rorsman, F., and Kämpe, O.: Autoimmune adrenal insufficiency: recognition and management. BioDrugs, 13(2):107-114, 2000.
14. Kellaway, C.H. and Cowell, S.J.: On the concentration of the blood and the effects of histamine in adrenal insufficiency. J. Physiol., 57(1-2):82-99, 1922.

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