This article follows on from Part 1: ‘Are you constantly tired? You’re adrenals may hold the answer.’

In that blog post we looked at the different stages of the General Adaptation Syndrome (GAS) which was developed by scientist Hans Selye in 1935. In his research he discovered that regardless of the type of stressor he imposed on rats, the same physiological response resulted and that the symptoms developed over time.

He stated that ‘stress is the non-specific response of the body to any demand made upon it’, which requires the body to make adjustment or adaptions to a new situation in order to survive and maintain homeostasis.

From his research, Selye hypothesised three stages of adaptation: alarm, resistance and exhaustion. For more understanding on the symptoms of each stage please refer to Part 1.

Here we will look more in depth into the last stage – the exhaustion phase – or rather the stage right before complete adrenal exhaustion or ‘burnout’, as this is where most people operate from for many years before experiencing complete burnout or adrenal insufficiency. This phase before the exhaustion phase is known as ‘Chronic Adrenal Hypofunction’ and is what most people commonly refer to as ‘adrenal fatigue’.

Chronic Adrenal Hypofunction

Chronic stress may cause significant demands on the neuroendocrine system and this may in turn cause fatigue. In adrenal hypofunction, cortisol levels are extremely low. Some of the symptoms that we’re going to see here include extreme lethargy, depression, exhaustion after doing small tasks, diabetes and even cardiovascular disease.

When stress is chronic or intense, and exceeds a person’s mental and physical resources, it becomes ‘distress’. Prolonged stress will over time disrupt the body’s natural hormone feedback systems responsible for mounting an effective stress response, which will consequently lead to adrenal hypofunction.

The circulating hormones will not return to the normal levels and initially stay in a state of hyper arousal. As a result, the hormones corticotrophin-releasing hormone (CRH), arginine vasopressin (AVP) and adrenocorticotrophic hormone (ACTH) are no longer inhibited via negative feedback, leading to dysregulation of the hypothalamus pituitary adrenal (HPA) axis. Further, target organs become overstimulated, receptors possibly become desensitised and tissue damage ensues.

This ‘wear and tear’ or ‘cost’ of adaptation has been termed allostatic load. It is implicated in numerous disease processes and has been associated with an energy deficient state of the body. It is mediated by adrenaline and cortisol. Both hormones actually serve to imprint the stressful event into long term memory, but prolonged action will cause damage to the part of the brain that should shut them off. This in turn leads to higher levels of these hormones circulating in the blood, known as cortisol resistance’, which can do more damage to the brain, especially the hippocampus.

Adrenal Burnout

After prolonged exposure to stress, there is a blunted response before cortisol levels will decline or the diurnal rhythm will flatten. With lowered cortisol levels, endogenous glucose production is compromised and sugar and stimulant cravings are likely as a consequence of the resultant hypoglycaemia. If untreated this can lead to adrenal burnout and subsequent chronic fatigue.

The flow on effects of these disturbances in neurotransmitters and stress hormones can also lead to exhausted serotonin levels, potentially resulting in anxiety and sleep disturbances. The precursor of serotonin is tryptophan. The established link between carbohydrate cravings and depression is thought to be due to the tryptophan increasing properties of carbohydrates, with mood elevating results.

Testing for Adrenal Hormone Abnormalities

If you struggle getting up in the morning despite getting adequate sleep, and your energy levels are low throughout the whole day then it is important to assess for potential HPA axis dysregulation before treatment is instigated. The tests below have been shown to be useful in diagnosing HPA axis dysregulation.

The information revealed in these tests will indicate not only the level of cortisol excess or depletion, and potentially which General Adaptation Syndrome (GAS) you are in, but also any concomitant health conditions that may have developed as a result of chronic stress, such as insulin resistance or inflammation.

Salivary cortisol Cortisol is diurnal – it is highest in the morning between 6-8 am and gradually tapers throughout the day, with lowest levels occurring around midnight.

Several reading will be taken throughout the day – upon waking, noon, 4 pm and 8pm to determine the diurnal rhythm of cortisol.

Any variation to the normal pattern of cortisol secretion will be reflective of HPA axis dysregulation.

With adrenal fatigue, the diurnal rhythm of cortisol has flat lined, with cortisol levels remaining low throughout the whole day.

ACTH (adrenocorticotrophic hormone) This hormone is measured through a blood test, and like cortisol, follows the same diurnal rhythm

ACTH needs to be present to stimulate cortisol release

If both cortisol and ACTH are low, an ACTH stimulation test should be performed to determine whether cortisol is low because of a lack of ACTH

ACTH Stimulation A synthetic form of ACTH is injected after taking a blood samples for baseline cortisol measurements

Blood samples are taken in half hourly intervals for the following one to two hours

If cortisol is still low Adrenal Exhaustion or Addison’s disease (primary hypoadrenalism) is the likely cause.

If cortisol levels are within the normal range, then the problem lies with inadequate ACTH secretion (hypopituitarism or secondary hypoadrenalism)

A three hour glucose tolerance test can be performed with half hourly measurements of glucose, insulin and cortisol

If hypoglycaemia is present, then cortisol levels should increase to activate glucose release from glycogen stores

Both the hypoglycaemia and low cortisol in response are indicative of Adrenal Exhaustion.

Inflammatory markers Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), homocysteine and antibodies should all be tested as low cortisol reduces the ability of the body to control inflammatory processes
Electrolytes altered aldosterone levels, due to mineral quote unquote insufficient to see as part of the quote unquote insufficiency can lead to imbalances in electrolytes notably sodium
Lipid Studies Cortisol is made in the body from cholesterol.

Further, in an insulin-resistant state, it is likely that triglycerides and possibly low density lipoprotein (LDL) are elevated with insufficient amounts of high density lipoprotein (HDL)

Viruses This is measured through a blood test to rule out any viral causes of fatigue



When a patient has the clinical presentation of stress and/or fatigue (not occurring from a diagnosed medical condition), the primary protocol is to establish which GAS phase the patient is in (alarm, adaptation, exhaustion).

For patients with acute stress, their adrenaline and/or cortisol is usually high. They may complain of anxiety, sleep issues and a range of somatic symptoms reflective of sympathetic nervous system up-regulation.

In cases of chronic stress leading to fatigue, hormones such as cortisol and adrenaline are generally low, resulting in a blunted stress response, and physical and mental exhaustion. There is energy depletion on a cellular level coupled with a lack of neurotransmitter precursors and/or cofactors.

The general aim of treatment is to assist in enhancing the function of the neuroendocrine system, thus increasing the energy and wellbeing of the patient. Since the HPA axis is stimulated by mental and emotional, as well as physical events, giving the patient resources not only requires support with nutrients, but also teaching better coping strategies. Aside from addressing nutrient deficiencies and prescribing nutraceuticals that modulate the neuroendocrine system, it is vital to consider an integrative approach to address stress and fatigue.

Naturopathic treatment aims will generally look at the following areas:

  • Address external factors contributing to stress

– consider social stressors and stress management techniques

  • Modify lifestyle

– work, rest, sleep, play balance

  • Enhance physical and emotional stamina and perceived wellbeing

– graded exercise, nutrition, relaxation/meditative techniques

  • Resource the body and mind to be able to deal with stressors

– low glycaemic load diet

– modify stimulate use

– nutritional supplements to replenish metabolic pathways (cortisol and neurotransmitter synthesis) – I commonly use B vitamins, co-Q10, SAMe, vitamin C and magnesium

– plant based adaptogens

Herbal Adaptogens and Tonics to Regulate the HPA axis and Reduce Stress and FatigueThe HPA axis activates, and is inactivated by cortisol. In the case of low cortisol, the negative feedback is impaired leading to dysregulation of other stress hormones.
Diet, lifestyle and thought patterns have a key influence on the HPA axis. Adjusting these aspects are the primary concerns as they will need to be the first line of defence for future stressors.

Certain herbal medicines, have been used traditionally to modulate the nervous system and the stress response. They may have potential roles in the three phases of the general adaptation syndrome. One of the most important herbal medicines modulating cortisol is licorice (Glycyrrhiza glabra). The constituents from licorice, specifically its active constituents, glycyrrhetinic acid, is a potent inhibitor of 11 beta-hydroxysteroid dehydrogenase, which converts active cortisol to inactive cortisone, thus increasing the amount of circulating cortisol. It is therefore ideally suited to cases of low cortisol, such as in the exhaustion phase, and contraindicated in the ‘alarm’ or ‘resistance’ phases.

Adaptogenic substances are innocuous agents, non-specifically increasing resistance to a range of stressors by normalising body functions and strengthening systems that are compromised by stress.


Rehmannia (Rehmannia glutinosa) is another adrenal herb which I often prescribe to my clients presenting with adrenal fatigue. It is a prime adrenal tonic and adrenal restorative. Rehmannia is used in traditional Chinese medicine to nourish the yin and invigorate the kidneys. It also supports the adrenal cortex and pituitary gland – possibly by antagonising the suppressive effect of glucocorticoids on the HPA axis. This herb also possesses anti-inflammatory and immunomodulatory actions.

I also prescribe herbal adaptogens to enhance endurance during fatigue, and to reduce stress-induced impairments to neuroendocrine or immune function. The following herbs increase physical and mental stamina and are well suited for those experiencing adrenal hypofunction or adrenal fatigue: Siberian ginseng (Eleutherococcus senticosus), rhodiola (Rhodiola rosea), American ginseng (Panax quinquefolium), Withania (Withania somnifera), Ginkgo (Ginkgo biloba) and Brahmi (Bacopa monnieri). The latter two also enhance cognitive function.

Rehmannia glutinosa

Following are some health and lifestyle tips that you can put into practice straight away to improve your energy levels, support optimal adrenal function and help manage your stress levels:


  1. Combine complex carbohydrates (such as vegetables and whole grains) with easy to digest protein and good quality fats (such as olive or flaxseed oil, ghee, nuts and seeds or omega 3’s)
  2. Reduce high glycaemic foods (highly processed refined carbs) and have adequate protein with each meal
  3. Meals should have an emphasis on different coloured vegetables and also eating a wide variety of different foods and rotating what is eaten. This will increase the amount of nutrients being consumed
  4. It is vital to cut out allergenic foods, reduce sugar and caffeine, and increase foods that are nutrient dense
  5. It is also important to eat meals at regular times every day, chew food well, and eat breakfast by 10 AM and again for lunch every day. Do not eat when you are feeling stressed, wait until you are feeling relaxed. DON’T SKIP MEALS
  6. Add salt to food (Himalayan or Celtic sea salt) especially upon rising and at least half an hour before your lowest energy point of the day – this can be beneficial in increasing energy and supporting your adrenals. A pinch of salt can also be added to a glass of water and drunk at these times.
  7. Stimulants such as coffee can be used sparingly, ideally before 1pm



  1. Be in bed before 10:00 pm
  2. Minimum 9 hours of sleep daily
  3. No screen use (mobiles phones, TV’s, laptops) for 1 hour prior to bedtime
  4. Graded exercise – avoid strenuous exercise, or for long duration, and avoid exercising in the evening
  5. Regular periods of rest/relaxation – take breaks, take naps if necessary – avoid getting tired or pushing yourself
  6. Look for things that make you laugh, laugh several times per day – (this increases the parasympathetic supply to the adrenals),
  7. Eliminate energy robbers (things in your life that drain your energy)
  8. Make your lifestyle a healing one
  9. Notice one thing to be grateful for each day



  1. Move your body regularly, breathe deeply into your abdomen several times a day
  2. Mindfulness based stress reduction: meditation, yoga and tai chi can assist in dealing with both mental and physical stressors and has been shown to reduce stress, anxiety and pain
  3. Physical therapies such acupuncture, massage, progressive muscular relaxation
  4. Stress management program: setting small tasks or goals to be accomplished each week to integrate better coping skills into daily life



Stress is something that we all experience but it’s how we handle it that will determine our long term health.

Stress becomes distress when it exceeds our physical and mental resources, and when you’re unable to continually adapt after prolonged periods of stress, adrenal dysfunction will begin to manifest. Most often, you will find that you’re unable to maintain previous levels of energy in all realms of life, and will progressively deteriorate as time goes by.

If you believe you may have adrenal fatigue, or are experiencing a lowered threshold to stress with plummeting energy levels, there is still much that can be done to regain your health and your ability to handle stress. Seeing a naturopathic practitioner is a great way to start this journey.

It is also crucial to get some testing done to determine which phase of the general adaptation syndrome you may be in. Again your practitioner can order these tests for you.

Looking at your situation, a treatment plan can be tailored specifically to your needs and lifestyle. Utilising herbal and nutritional medicine, as well as holistic lifestyle changes, naturopathic medicine is a powerful tool in your arsenal against stress and adrenal fatigue.

To good health

~ Michelle