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"Providing information and resources to promote effective diagnosis and appropriate treatment for people with thyroid disorders in the UK" |
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"Providing information and resources to promote effective diagnosis and appropriate treatment for people with thyroid disorders in the UK" |
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It is the cortisone production by the adrenals that concerns us. This is the hormone which enables the body to deal with mid and long-term stress. On our ability to produce this hormone depends our capacity for fighting off the effects of environmental challenges. Injury, illness (especially undetected thyroid disease), deprivation, work or personal stress. Cortisone is the hormone needed by the body to combat stress. It is produced regularly and constantly, with peaks and troughs. The highest levels are in the morning, declining as the day progresses, and building up again during the small hours. Although the word cortisone may worry you – and we will return to this later – it is a natural substance that we all make and need for our health. In normal health, we make it all our lives, with fairly minimal falling off with age. Problems arise, however, if the adrenals go wrong. This may happen in two was. The first is overproduction of cortisone. This may occur with overproduction of ACTH by the pituitary. This may be a physiological response to high levels of stress. Stress is used here in its broadest sense; illness, trauma, surgery, or the stress of living in difficult times. This physiological overproduction will not cause a problem generally, since adjustments are automatic; but if there is a hormone-producing growth on the pituitary, and it produces too much ACTH all the time, then the overproduction may have damaging effects. A similar hormone-producing tumour (an adenoma) on the adrenal gland itself will cause the same overproduction of cortisone. (This can certainly involve other hormone-producing cells of the adrenal, with additional problems). This condition is Cushing’s disease. Though not especially common, it is seen today more as the result of over-medication with cortisone, which is used in high, therapeutic doses, for a number of conditions including rheumatoid arthritis and related conditions, asthma and chronic allergic disorders. The patient puts on weight, developing a potbelly and rounded moon-face; they develop a thinner, weaker skin, become liable to bruising, and become subject to fluid retention. The treatment is to find the adenoma and surgically remove it; or reduce the amount of cortisone being given. We are concerned with the opposite end of the scale, which is a great deal more common, but which in its milder form may escape detection. In its standard, more severe form it is called Addison’s disease. Thomas Addison described a disease in 1855, where the patient had become chronically ill, with lethargy, anorexia, low blood pressure – low enough to cause fainting attacks; hypoglycaemia (extreme sensitivity to lack of carbohydrate and sugars in the diet); a poor response to even mild illness, and a risk of sudden collapse or even death when subject to illness, injury or shock. These unfortunates classically developed a pigmentation, especially in skin folds and creases, but also generally. They pursued a steady downhill course, until their death. What struck Addison was that there seemed little to find at postmortem – except both adrenals were taken over by TB bacilli, and consequently not working. Today the adrenals are more likely to be damaged by other processes, most commonly autoimmune diseases; but the principle is the same. There is a steady loss of function, with accumulating symptoms of an illness, which, untreated, will end in death. While gross adrenal failure is not too difficult to diagnose – if it is thought about – it is partial adrenal failure we are concerned about. Its fully developed form, Addison’s disease, is not often seen in clinical practice. But we are concerned with a lesser degree of deficiency which it is convenient to call Low Adrenal Reserve. Here, the patient may be well, until subjected to stress and/or illness. Then, many of the symptoms may appear together with prostration and collapse; or there may be a level of insufficiency present all the time, with varying degrees of weakness, muscle and joint complaints, and general ill-health. Symptoms So what do we look for in the way of symptoms? It is rarely clear-cut, because the deficiency is so often part of another illness, and may therefore have something of the symptoms of both. We are particularly concerned with thyroid deficiency, which, if of long-standing, or fairly severe in degree, is most often associated with adrenal weakness, as well as a direct result of the stress on the system that low thyroid function will cause. The patient will complain of weakness and episodes of prostration, frequently feeling quite unwell without being able to pinpoint the cause. Episodes of dizziness, sometimes with cold sweats, caused by the blood sugar becoming abnormally low, are not uncommon. Often, an odd internal shivering is described. Aches and pains of a rheumatic nature together with a backache in the region of the loins, is another frequent complaint. The patient is troubled by cold, and is likely to be cold to the touch. They do not feel well, and may look ill, with a general pallor contrasting with dark rings under the eyes. There are likely to be problems with digestion, with excessive wind and bloating and bowel disturbance. The menstrual cycle may very well be out of kilter and the libido may be absent or low. Depression and anxiety may also be a feature. Some of the symptoms complained of by patients with ME/CFS/Fibromyalgia are very similar, leading to the well-grounded suspicion that this condition is associated with Low Adrenal Reserve. Frequent minor illnesses are common, with an overlong course of minor infections, which may have an unexpectedly severe effect on the patient. You may have noticed that low thyroid function has some of these features, and it may be difficult to distinguish one from the other (see Low Adrenal Reserve Symptoms List). In fact it may not be necessary because as the two are often seen together, their treatments will overlap and be designed to relieve both. SignsIf the symptoms suggest the possibility of low adrenal reserve, we must then look for the signs to establish the diagnosis. Actually it is sometimes difficult where the problem is not particularly severe: but there are some pointers. The blood pressure is usually low, often strikingly so. The difference between the lying (or sitting) blood pressure and the standing reading is abnormal. Normally the systolic (upper reading) rises when the patient stands, but in low adrenal reserve, it either does not change at all or it drops. The pupillary reflex (the response of the pupil to bright light) is slow or unstable, or even reversed. Tendon reflexes may be abnormally slow, especially the Achilles reflex in the heel. It is satisfactory to confirm the clinical impression by blood tests; but these are sometimes unhelpful. The level of cortisone in the blood may be so widely variable as to be almost useless. The measurement of DHEA (Dehydroepiandrosterone) is quite a good indicator of adrenal cortex function. It may well be low or its normal diurnal variation may be distorted. Both salivary testing and the estimation of urinary hormone excretion are excellent indicators and available privately (see Current Tests for Thyroid & Adrenal Function). TreatmentA particular problem of treating a hypothyroid patient who also has unrecognised low adrenal reserve is that the provision of thyroid supplementation without dealing with the adrenal weakness may at worst precipitate an adrenal crisis, where there is sudden acute adrenal exhaustion and consequent shock, which may be fatal. What usually happens is that the thyroid replacement might either not work at all or the patient may quite soon suffer from symptoms of thyroid overdosage even on quite low levels of thyroid replacement, due to conversion or uptake failure. Hence, where low adrenal reserve is suspected, it is possibly dangerous, and certainly ill-advised, to treat the patient without supplementation of the adrenal weakness first. One approach is to use natural adrenal glandular extracts, which are easily obtainable without prescription (see Resources). The other approach is the use of hydrocortisone (10 mg tablets). Half a tablet, 3 or 4 times a day is usual, later to be increased if required. Hydrocortisone has the problem of very rapid uptake by the system, and since it should be given every four hours, this creates practical problems for many patients. Instead of this, Deltacortril or Prednisolone, which last in the body for 24 hours may be given: 2.5 mg daily is usually given to start with, increasing to 5 mg or even 7.5 mg. Most patients feel benefit within a few days, although it sometimes takes many weeks for all the benefits to come through. Some improvement should be obvious within a week or so. In a large number of cases the adrenal insufficiency related to low thyroid function corrects itself as thyroid levels improve, and after a period of a few weeks or a few months, the adrenals will have recovered sufficiently for the cortisone therapy to be stopped. The question is often asked: will the cortisone replacement suppress my adrenals? The answer is that in physiological (that is approaching a natural dose) it does not at all. And in any event since the adrenal activity is curtailed anyway there is no other option. Suppression does occur in supra-physiological doses, which do not concern us in this context. Even then, the adrenals are usually able to recover, if the primary illness is dealt with, and the dose then reduced gradually. Low adrenal reserve means that under a state of challenge, the problem is going to show. While on replacement treatment therefore, any further illness and stress is best dealt with by a temporary increase of dose. Influenza, heavy colds, dental extraction, injury and the like, require, for example, 5 mg deltacortril to be doubled for a few days; (some people have noted that a 5 mg dose almost completely prevents jetlag; and influenza is over in 1 or 2 days). Risk Factors for Adrenal StressLifestyle Adrenal hormones are required for proper T4 → T3 conversion and tissue uptake. If their blood levels are becoming low, due to adrenal exhaustion, you may become subject to a mix of symptoms with weight loss, diarrhoea and anxiety, suggesting over-activity of the thyroid, when in fact your thyroid status may actually be under-active, due to the thyroid hormones not being processed. In this situation it is essential to provide adrenal support before treating the under-active thyroid. Exercise is very important but must be in moderation to avoid further stress on the adrenals. Exercise can help rebalance cortisol and can increase endorphins and serotonin levels. However, over-exercising can be as bad as doing too little. A regular brisk walk is probably the best way of achieving this, until adrenal health is restored. Diet Crash dieting puts increased stress on the adrenals by requiring an increased level of cortisol to promote the breakdown of fats and proteins in to sugar to maintain normal blood sugar levels. This has the additional undesirable effect of thyroxine being converted to reverse T3 (the inactive thyroid hormone), thus slowing down the metabolism very rapidly, causing further adrenal stress. All adrenal hormones are made from cholesterol, so a very low cholesterol diet may lower adrenal output. Vitamin C is found in greatest concentration in the adrenals, and the B group vitamins are also important. Low adrenal reserve affects adversely the absorption of vitamin B12, which can cause fatigue and pernicious anaemia, which can be revealed by a simple blood test. This is treated with monthly injections of vitamin B12. A refined carbohydrate/low fat diet, so often followed today, is not to be recommended. Try to keep all stimulants such as tea, coffee and alcohol to a sensible level. Environmental Influences Being Female |
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