Adrenal fatigue in women, or HPA axis dysfunction, develops as we throw ourselves into life. We have a sense of purpose: we work hard, we take care of our families, and we do our best. But… sometimes we overdo it, and the stress mounts. Our bodies cannot handle it, and the result is a condition called adrenal fatigue.

“So much time, so little to see…wait a minute–strike that, reverse it.” 

Willy Wonka in Charlie and the Chocolate Factory

There are 168 hours in a week, so there should be plenty of time to indulge in a few self-care hours, right? Put your feet up. Lounge in the tub. Hit a yoga class or two. Binge watch Real Housewives. 

Counting the physical cost of “doing it all”

So why do we feel like there is no time left at the end of the week when all of the other priorities are scratched off the list? And why is it that when all of those priorities are tended to, with neat little check marks in front of all of the items on the to-do list, we feel sapped, not exhilarated? 

Women know how to get stuff done. We save the baby, wipe the bottom, chat with the teenager, and run a business simultaneously. Meanwhile, the oven is preheating and there is a load of laundry running. But there is a cost for all of this capability. 

Dubbed “Superwoman Syndrome,” today’s woman is more stressed, more depleted, and more unhealthy than ever before. 

And my clinical experience tells me there’s more adrenal fatigue in women than ever.

Superwoman syndrome and adrenal fatigue

Some days we feel like the Woman of Steel. Other days the weight of grocery lists, toddler meltdowns, and emails at work needing our immediate attention threaten to take us down. 

Superwoman Syndrome describes the modern-day woman’s attempt to do it all. She works (often in demanding, fast-paced professions), she organizes the family home and keeps it running, and she takes on the lion’s share of childcare. She volunteers for PTA and nurtures friendships (her own and her children’s). She climbs the corporate ladder AND the squishy stairs of the bouncy house with her 3-year-old. 

You might be thinking, “We all work hard. That’s just a part of life!” Sure–we have things to get done. But what about all of the choices we make that are optional? And how about the impact of our “busy-ness” on our health? At some point doing more means we are operating with less: less stamina, less sleep, less attention to self-care, less ability to focus.

Your body can only handle this for so long. Your body’s adrenal glands produce extra stress hormones, such as cortisol, to give you the energy to keep up with this crazy lifestyle. But if your adrenals keep overproducing for too long, your body simply stops responding to cortisol. The result is overwhelming, crippling exhaustion. That’s what adrenal fatigue syndrome (HPA-axis dysfunction) looks like.

Your symptoms ARE real

Everyday in my practice, I meet women who are just hanging by a thread. They are exhausted, emotional, hormonally imbalanced, and often ignoring their basic needs (sleep, exercise, good nutrition)—all so that they can take care of everything at home and at work. 

Most—if not all—have hypothalamic-pituitary-adrenal axis dysfunction (also called HPA-axis dysfunction). Of course, in lay terms, a lot of people just say “adrenal fatigue.”

But adrenal fatigue?

If you want to see an endocrinologist get fired up, tell them “I think I have adrenal fatigue.” Just stand back while they go off. They will march you right out the door. 

But you’re not crazy. You know your body is telling you something is off.

Your symptoms are real. And they can be measured, evaluated, and appropriately sorted out. 

If you aren’t receiving a personalized care plan that looks at root causes, deeply analyzes all related problems, and is delivered by a physician who will hang in there with you for the long run, you aren’t receiving the care you deserve.

What is the HPA Axis, and why does it matter?

Hypothalamus

Whenever you read about “adrenal fatigue,” you’ll see a lot about cortisol, one of the stress hormones produced in the adrenal glands.

However, there’s a small gland in your brain called the hypothalamus that first initiates the process of creating cortisol. It does so by stimulating the pituitary gland—also in the brain and right next to the hypothalamus—with corticotropin-releasing hormone (CRH). This is the first step in your stress response system.

The hypothalamus is also responsible for many other hormonal responses in many parts of your body via its direct influence on the pituitary. Using the pituitary as a go-between, it influences sex hormones, water retention, and your metabolism.

Pituitary Gland

The pituitary gland is a small pea-sized gland controlled by your hypothalamus at the base of your brain. It controls the hormone production of most other hormone-secreting glands. It is, in essence, the Master Gland of your body.

When you feel stressed, the pituitary gland stimulates the adrenal glands with adrenocorticotropic hormone (ACTH). ACTH tells the adrenal glands to start producing cortisol.

The pituitary gland sits close to nerves from your eyes and nose…

This is an interesting point. The sensory input from what you see and smell have a profound impact on how your pituitary gland filters stress. You might not be able to completely control the things you see and smell on the road, for example. However, knowing this, you do have control over some of what you put in front of yourself at home.

Thus, a hot bath with sweet smelling herbs doesn’t just feel good to the body. You’re sending a message of relaxation to your pituitary gland. The sunsets and mountaintop views aren’t just superfluous extras in life; they are opportunities for your body to heal from stress.

Adrenal Glands

Your adrenal glands sit atop each of your kidneys. They produce many important hormones. Some of these hormones help the body manage fluid levels. The adrenals also produce small amounts of estrogen, progesterone, and testosterone in both women and men. 

Most importantly, adrenals are the epicenter of our stress hormones: 

• Adrenaline (or epinephrine)
• Noradrenaline (norepinephrine)
• Cortisol

Adrenaline and noradrenaline

Adrenaline and noradrenaline are responsible for the feeling of “butterflies in the stomach” when a threat occurs. Someone cuts you off on the highway–whoosh! There they are. Their job is to help you react quickly to a threat. They are life-savers when you need them! Thankfully, adrenaline and noradrenaline break down quickly and leave the body, and we go on with life. 

Cortisol

Cortisol is a different beast. In normal amounts, cortisol is anti-inflammatory and helps your wounds heal. If you’ve ever wondered why sometimes a mosquito bite swells up to the size of an egg and other times is barely visible, cortisol may be the answer. Obviously, if you’ve been in battle, your body will need a little extra cortisol to survive the ordeal. 

But research shows prolonged stress reduces your body’s sensitivity to cortisol. Thus when life is going great, your cortisol levels are balanced and your immune system functions well. However, if you’re living through the stress of a divorce or infertility, your immune system doesn’t function at its best due to your imbalanced cortisol levels. That’s why, during stressful life events, it can feel like you catch every virus that comes your way.

Less obvious internal triggers may also initiate our stress response:

• Did I do OK on that presentation? 
• When is that proposal due? 
• Are my children happy?
• How will I take care of my aging parents?
• How will we pay for the house or college tuition or whatever?
• What do others think of me?

Cortisol soars, or soars and drops. If elevated cortisol levels are left unchecked for a long period of time, your body may start to ignore it.

Your focus is gone. Your weight is up. Suddenly you don’t recognize yourself. 

Inflammation and chronic fatigue are your body’s new default.

What is adrenal fatigue?

Adrenal fatigue is a bit of a misnomer. It is the lay term used by many people to describe HPA axis dysfunction (or HPA-D). Adrenal fatigue feels easier to say and remember, so it’s certainly understandable that this term persists. However, it is based on an outdated theory.

The theory went that if you’re exposed to too much stress, you’ll overproduce cortisol at first. This then leads to “fatigue” of the adrenal glands, where they no longer produce adequate cortisol effectively and bottom out.

The reality is a little more complicated. Prolonged stress produces fatigue, inflammation, and disease, but people’s cortisol levels don’t necessarily “bottom out” each time. Actually, sometimes if you’re stressed, you’ll overproduce cortisol in the evenings, when you need lower cortisol levels to sleep.

In fact, research shows different kinds of stress influence different cortisol curves. A healthy cortisol curve should be high in the morning and low at night. 

• Stressors that are uncontrollable, traumatic, or present a physical threat to you cause your cortisol curve to present with persistently high levels. It will have higher-than-average levels in the morning and higher-than-average levels at night, with—no surprise—a higher-than-average total.
• Stressors that feel controllable, however, tend to cause an extra high cortisol spike at the time of the event, but quickly return to normal levels 
•  Stressors that occur for a long period of time such as a prolonged illness or within a long dysfunctional relationship, or PTSD, are associated with lower-than-average production of cortisol across the board.

In the first example, you would have overall higher levels of cortisol than average, and feel awful. But in the third example, you would have overall lower levels of cortisol than average, and feel awful. In both cases, you probably feel fatigued, suffer from more sickness and inflammation, and are at risk for other medical problems.

That’s why “adrenal fatigue,” if we’re assuming it just means too low cortisol levels from poorly functional adrenal glands, is probably inaccurate. But your fatigue and your symptoms are real.

It’s just there’s another more accurate term: HPA-axis dysfunction.

But, if we use the term the way it’s used in pop culture, then adrenal fatigue is a collection of symptoms associated with an imbalance in the adrenal glands and the rest of the HPA-axis. Adrenal fatigue (HPA-axis dysfunction) can develop with intense or prolonged physical or emotional stress. 

Remember, prolonged stress isn’t limited to trauma-inducing stress. Just being a mom can be stressful. Or running a really successful business. Or not being able to become a mom. Or whatever life has thrown at you. Life can be stressful.

Burnout from doing all the things is real and stressful.

And prolonged stress puts strain on the HPA-axis and reduces your tissue’s sensitivity to cortisol.

From here on out in this article, we will use adrenal fatigue with the common lay definition because:

1. It’s a lot easier to say.
2. Some of you are arriving here from Google or Bing after searching “adrenal fatigue,” and you deserve answers as much as the woman who knows to search “HPA-axis dysfunction.”

Signs and symptoms of adrenal fatigue, or HPA-D

Because the HPA-axis impacts so much of your daily functioning, the symptoms of adrenal fatigue are quite varied. These are some of the most common:

• Fatigue that is not relieved by sleep 
• Wired but tired
• Early morning awakenings
• “Non-refreshing” sleep 
• Weight gain
• Brain fog
• Deteriorating memory and concentration

Why your doctor hasn’t talked about HPA-axis dysfunction with you

Unfortunately, many physicians do not recognize “adrenal fatigue” as a medical condition and will not talk about HPA-dysfunction. That means patients often suffer for many years–or worse, are misdiagnosed with conditions like depression–prolonging their suffering.

Why are adrenal fatigue symptoms ignored by so many physicians?

Think about what the typical physician does: 

• Meet a patient.
• Listen to a list of symptoms and complaints.
• Diagnose a disease.
• Prescribe a pill or procedure.

There is no pill or surgical intervention for HPA-axis dysfunction. The problem is your deadly exposure to stress.

There are only two possible fixes:

1. Reduce your exposure to stress.
2. Improve your response to life’s stresses.

That’s it. While adaptogenic supplements can support your adrenal system and may help your body cope with stress, your long-term plan still must deal with reducing your stress level and improving your stress responses. 

Neither of these adrenal fatigue “therapies” fit in current transactional medical model, certainly not in a 10-minute visit.

A treatment plan for stress has to take into account your lifestyle and a deeper understanding of the things you can and cannot change. For example, you might be able to prioritize time to wind down each day, but you probably can’t change how your mother-in-law treats you. Some stressors are not going away.

A plan to heal from HPA axis dysfunction includes learning to deal with the stressors you cannot change. Most doctors do not have the mental health training to even start that conversation.

The evidence for HPA-axis dysfunction (“adrenal fatigue”)

The fact that your primary physician doesn’t talk to you about HPA-axis dysfunction doesn’t mean it’s not real. There are thousands of articles on Google Scholar on HPA-axis dysfunction.

The Current Scientific Consensus

In fact, there’s research linking the HPA-axis to a broad range of disorders: from depression to PTSD, from low libido in women to Alzheimer’s disease. In fact, HPA-axis dysfunction correlates to obesity and heart disease, as well. While there’s a genuine need for more scholarship, there’s a growing scientific consensus that stress profoundly impacts your health, and it does so by way of the HPA axis.

Researchers also spell out what a healthy HPA-axis looks like, and how it functions. When we know what’s right, it’s easier to identify what’s wrong.

That’s not necessarily the same as a scientific consensus as to what constitutes HPA-axis dysfunction or how to diagnose it, however.

But the research does continue to point us in the direction of fatigue. Recently researchers demonstrated a link between HPA-axis dysregulation and chronic fatigue syndrome. When the HPA-axis gets out of balance, it leads to terrible, unremitting fatigue. Moreover, untreated HPA-axis dysregulation “is a poor prognostic factor” with “more established psychological, behavioural, or pharmacological treatments” of fatigue.

Likewise, an abnormal cortisol curve has been associated with a poor prognosis in both metastatic breast cancer and lung cancer. This finding is significant, because it demonstrates the importance of finding out what your cortisol curve looks like when you may be suffering from HPA-axis dysfunction. An abnormal curve warrants attention and further investigation. Most functional medicine practitioners look for your cortisol curve via multiple saliva tests during a 24-hour period.

How is adrenal fatigue diagnosed?

Many conventional physicians will not make a diagnosis of HPA-axis dysfunction (the official term for adrenal fatigue). You will need to see a functional medicine practitioner or naturopathic doctor to get tested.

Testing for adrenal fatigue (HPA-axis dysfunction) involves collecting saliva samples at four different times over a 24-hour period. This is a simple test, and you can do it at home with a test kit.

We also often check DHEA-S (a hormone that helps the body manufacture other hormones, including cortisol). Low levels can indicate HPA-axis dysfunction as well.

Treatment for adrenal fatigue (HPA-axis dysfunction)

You didn’t get here overnight, and there’s not a quick fix to adrenal fatigue (HPA-axis dysfunction). Adrenal fatigue in women is usually a result of trying to do all and be all. Something has to change.

If you’ve gotten to this section of the article looking for a magic pill, you won’t find it. In fact, supplements and herbs to treat adrenal fatigue are only a piece of a bigger picture. Addressing imbalances in your stress hormones requires a holistic approach. 

Lifestyle changes to treat adrenal fatigue

If you have adrenal fatigue (HPA-axis dysfunction), stress is affecting your body in real ways. Your body is telling you something’s wrong. You cannot keep going at your current rate without change and expect to heal. You must learn to manage stress and your workload effectively. This may mean cutting back on activities that stress you out or identifying activities that help you destress. 

Habits that will help you recover from adrenal fatigue include self-care activities, such as:

• Meditation and slow breathing
• Gentle regular exercise
• Good sleep hygiene
• Healthy eating

It may also mean paying closer attention to your sensory input. Remember that the pituitary gland’s stress response, in essence, gets “filtered” by your eyes and nose. (Note: these sense also have deep neurologic connections to your limbic system, which is the emotional part of the brain.)

• Are you allowing your eyes to rest on beauty?
• Do you stop to watch the leaves change in the Fall or the flowers come out in the Spring?
• Have you filled your nose with smells that make you happy?
• Would a cup of mint tea or a little lotion with pure essential oils help?

Asking yourself these questions allows you to put into place healing routines.

Your doctor will likely recommend that you get in tune with your circadian rhythm. Since the adrenal glands (and therefore your cortisol levels) are regulated by the circadian rhythm, regular sleep and natural lighting are essential to balancing your cortisol levels.

Supplements and herbs to treat HPA-axis dysfunction

Supplements and herbs can also play a crucial role by providing specific nutrients needed. There is no one-size fits all approach — everyone requires and deserves an individualized approach. If you suspect you may have adrenal fatigue, a functional medicine practitioner or naturopathic doctor can help create a treatment plan that fits your body’s needs. 

Some supplements they might prescribe include:

1. Vitamin C 
   • Your adrenal glands have the highest connection of vitamin C in your body. Also, you use up vitamin C more rapidly when you’re stressed. This can lead to depletion and reduce your ability to make cortisol. 
   • Food source: citrus fruits, bell peppers, broccoli, Brussels sprouts, and dark leafy greens
2. Magnesium 
   • Your body requires magnesium to make cortisol, and it’s also one of the most common nutrient deficiencies. 
   • Amino acid chelate forms of magnesium, such as magnesium citrate or glycinate are well-absorbed and help support healthy cortisol levels. 
   • Magnesium also promotes sleep and muscle relaxation, which are important for the overworked woman.
   • Food source: greens, nuts, seeds, and beans
3. B-Vitamins
   • Your body needs certain B-Vitamins, especially pantothenic acid (vitamin B5), to make cortisol when you’re stressed. 
   • Taking a high-quality methylated B-vitamin complex can help improve your energy and mood. 
4. Adaptogens
   • Adaptogenic herbs or “adaptogens” are a unique group of plants that help to mediate stress and can improve your physiologic response to stress. 
   • Common adaptogens used to improve adrenal function are ashwaghanda, holy basil, rhodiola, ginseng, and licorice root. 
   • Your functional medicine doctor will recommend specific adaptogenic herbs based on your cortisol curve as well as your symptoms, whether you are exhausted, stressed and anxious, or feel wired and tired.   

Your doctor may recommend other herbs and nutrients to reduce inflammation, balance blood sugar, or reduce anxiety.

Rarely, prescription medications are needed to help severe HPA-axis dysfunction. 

What does recovery from adrenal fatigue look like?

Recovering from HPA-axis dysfunction is a journey, and we are here to help you every step of the way. People who are able to make lifestyle changes early on–such as decreasing caffeine use, actively managing stress and eating nutritiously–improve quicker than those who don’t participate in these changes. 

In my clinical experience, most women will see improvements in their fatigue and sleep within the first few months of treatment and are fully recovered within 12-18 months. Your clinician may recommend repeat saliva testing 1-2 times per year to track your progress until you are better.

Don’t waste years waiting for the fatigue to end.

No matter your phase of life, if you’re struggling with fatigue, get help. Adrenal fatigue in women is so often a result of society’s expectations, but we don’t have to fall victim to it. Talk to a functional medicine or naturopathic doctor, like the doctors at Vytal Health. You don’t have to wait until the kids leave the house or your job settles down to start feeling better.