6 Adrenal Myths: Why “Adrenal Fatigue” Isn’t Real and What Actually Matters

“My adrenals are shot.” If you’ve said some version of that sentence this year, Dr. Komal Patil-Sisodia believes that you feel terrible—she just wants you to know that adrenal fatigue isn’t a real diagnosis, a lab value, or something your adrenal glands can actually do. In this myth-busting episode, she takes on six widely held beliefs about the adrenal glands: from the supplement industry built around a condition with no validated test, to when an adrenal tumor actually needs surgery, to who really needs Cushing syndrome screening, to how peri-operative steroid dosing has changed. She closes with the myth she considers most dangerous—that real adrenal insufficiency is easy to spot—and explains why it’s so often missed for years, sometimes until a life-threatening adrenal crisis forces the diagnosis.

Timestamps
00:00:  Welcome to Clearly Hormonal

01:03:  Setting up the adrenal fatigue myth

02:17:  Myth #1: “Adrenal fatigue” isn’t a real diagnosis

04:47:  Myth #2: Are adrenal support supplements safe and effective?

06:18:  Myth #3: Does every adrenal tumor need surgery?

07:57:  Myth #4: Should everyone with obesity or diabetes be screened for Cushing syndrome?

11:00:  Myth #5: Does everyone on chronic steroids need stress-dose steroids for procedures?

12:38:  Myth #6: Is adrenal insufficiency easy to diagnose clinically?

15:58:  Recap and what’s coming next

Thanks for listening. Find more info about Clearly Hormonal on the website or Instagram.

Transcript

Dr. Komal Patil-Sisodia 0:01

Welcome to Clearly Hormonal, the podcast where we stop googling our symptoms at midnight and actually start understanding what's going on in our bodies. I'm Dr. Komal Patil-Sisodia, an endocrinologist, internist, obesity medicine specialist, and a Menopause Society certified practitioner, which is really just a whole lot of words to say hormones are kind of my jam. I've spent 17 years watching women try to navigate their hormonal health without ever having been taught the language for what's happening in their own bodies, and then meeting clinicians who want nothing more than to help them figure it out, but are up against 10-minute appointments and a system that just wasn't built for it. This podcast is my answer to that gap. We'll cover menopause, metabolism, hormones, and everything in between with real evidence, not trends, and without the overwhelm. A quick disclaimer: I'm a physician, but this is education, not personalized medical advice. Take what resonates and discuss it with your own healthcare team. Now, let's get into it and talk about what's clearly hormonal and what's not. My adrenals are shot. I'm in adrenal fatigue. I need to support my adrenals before they completely burn out. If you've said any version of that sentence in the last year, first, I believe you that you feel terrible. Second, I need you to know something that might genuinely change how you think about your own body. There is no such thing as adrenal fatigue, not as a diagnosis, not as a lab value, not as a thing your adrenal glands can do. Today, we're going to do a full myth bust on the adrenal glands, six things almost everyone gets wrong, including, in some cases, well-meaning clinicians. Stick around because myth number six is the one that actually keeps me up at night because it's the one that delays real diagnoses for years Welcome back to Clearly Hormonal. I'm your host, Dr. Komal Patil-Sisodia. This episode is part of the myth-busting series, and this is the adrenal installment. I take claims everyone has heard, I tell you what the actual evidence is and what the guidelines say, and I tell you why the myth persists anyways. So let's get into it. Myth number one, adrenal fatigue is a real medical diagnosis. This is the myth that built an entire wellness industry. So let's take it apart carefully. The idea is that chronic stress eventually, quote, "exhausts your adrenals." They stop making enough cortisol, and that's why you're tired, wired, and running on fumes. It sounds plausible, but it's not really how the adrenal gland or the hypothalamic pituitary adrenal axis actually works. A few things that you need to know. No major endocrinology society recognizes adrenal fatigue as a diagnosis. The American Association of Clinical Endocrinologists has a position statement that's very clear. It's a condition not recognized by endocrinology specialists, and the tests that are marketed to, quote, "diagnose" it have never been validated against a real reference standard. There's no real reproducible mechanism showing chronic stress can cause adrenal glands to physically wear out. That's not really how cortisol regulation works. The adrenal gland doesn't just run out because it's tired. There are other reasons why an adrenal gland can shut down, but that is not the same thing as adrenal fatigue. And this isn't just an argument over words. Treating imaginary adrenal fatigue can actually mask a real diagnosis. True adrenal insufficiency, thyroid disease, depression, sleep apnea, anemia, all of which have a similar I'm exhausted and nothing really helps feeling. And when adrenal fatigue protocols include hydrocortisone, there's trial data in chronic fatigue syndrome showing it does not meaningfully improve energy. So even the treatment people reach for doesn't deliver on its own premise. What I want you to walk away with, there's no test, no scan, no lab value that diagnoses adrenal fatigue because it isn't a diagnosis. It is a description of a feeling wearing a lab coat. To be clear, I'm not telling you that your exhaustion isn't real or that your nervous system can't be in a chronically dysregulated state from stress. What I'm telling you is that the adrenal gland isn't the broken part, and calling it adrenal fatigue often stops people from finding what the actual problem is. Let's move on to myth number two. Adrenal support supplements are effective and safe. If myth number one is a diagnosis that doesn't exist, myth number two is the industry that sells you the cure for it. These adrenal support supplements that you often see on social media or on your webpage are frequently marketed as hormone-free, and yet the testing has found that some actually contain real thyroid and steroid hormone, but it's undeclared on the label. In people without confirmed adrenal insufficiency, supplementing with things like pregnenolone or DHEA doesn't improve how people feel. It mostly causes acne, hair changes, and other side effects that you can get from taking things that are androgenic or similar to testosterone. So that can be hugely problematic. DHEA does actually have a real evidence-based role, but only in women with confirmed adrenal insufficiency who have specific symptoms like low libido, fatigue, depression. And even there, the benefit is minimal, like modest. It's not a dramatic transformation like the bottle will promise you. So if you don't have a diagnosed adrenal problem, an adrenal supplement isn't really supporting anything. It's just an unregulated hormone that you didn't ask for, or an unregulated bunch of herbs that are not proven to do anything, especially for a condition that doesn't exist Now let's move on to myth number three: every adrenal tumor needs surgery. This is one that I constantly see in my clinic. Somebody gets a CT scan for something totally unrelated, and the radiologist notes adrenal nodule. And the patient spends, like, the next three weeks convinced that they need surgery. Adrenal incidentalomas, which are incidental findings or adenomas that we see on other scans, show up in about one to five percent of CT scans. And the overwhelming majority of those adrenal tumors are benign, non-functional adenomas, meaning not cancer and not overproducing any hormones. Now, the current guidelines are pretty consistent. When we have a benign-appearing non-functional adenoma, they don't need surgery. They need monitoring, not an operating room. So we'll generally monitor those over a period of time. If they're continuing to grow or they are larger in size, like four centimeters or bigger, then we'll talk about actually going and sending people for surgery. We will also operate on patients who have tumors that are overproducing hormones that can cause issues like high blood pressure or Cushing syndrome, or when you have an excess of those adrenaline-like hormones, that's called a pheochromocytoma. There are true conditions where hormones are being overproduced that you do need to remove the adrenal to help manage those symptoms. But in people who have no symptoms and the tumor is less than four centimeters in size, that's actually something you can watch pretty safely. Now let's move on to myth number four, which is that everyone with obesity or diabetes should be screened for Cushing syndrome. Cushing syndrome gets a lot of attention because when you look it up and you Google it, the presentation is really dramatic, right? People will gain weight around their middle. They'll lose muscle mass in their arms or legs. If they have a pituitary gland tumor that's overproducing the hormone that stimulates the adrenal glands, people can get very dark stretch marks along their abdomen. They can have hair loss and acne, and they get a round appearance of their face, and they get kind of a hunched over appearance of their back. So those types of symptoms are concerning for Cushing syndrome, but just because you have obesity and diabetes does not mean that you have Cushing syndrome, right? People are often told your cortisol is the reason you can't lose weight, but in reality, it's a rare cause of obesity and diabetes, not a common one. So screening every person with obesity or diabetes for Cushing syndrome isn't recommended by any guidelines. It would actually create a flood of false diagnoses without actually finding more real disease. There's no single symptom that points to or is a definitive thing that Cushing's syndrome presents with. And a high cortisol level by itself isn't actually diagnostic because your cortisol levels naturally fluctuate up and down throughout the day with something called diurnal variation, which is the way our body is supposed to produce and use up cortisol and then kind of recharge it overnight. Your cortisol level will naturally fluctuate throughout the day, and those fluctuations get worse when you have stress or illness as well. And so testing should really be reserved for people who have a very specific clinical pattern that will make you suspicious for Cushing's. So dark purple colored stretch marks, muscle weakness because you've lost muscle tone in your arms or legs, and then unexplained osteoporosis in someone who's young. I've had a few patients in my practice where their diabetes is something that we can't control no matter what we put them on, and they are following their diet. And it's unfortunate, a lot of times these patients will get told, "Well, you must not be doing the diet part" or "You must not be exercising enough." But what I've seen in these patients who end up having Cushing's syndrome is that no matter what we do, no matter what diet they follow, because the cortisol is high, it's driving up the sugars, and insulin and other medications don't treat it appropriately. So that's something to keep in mind if you have symptoms like that and nothing is working. In that case, it kind of makes sense. You should probably get screened for Cushing's. But for the overwhelming majority of people, it's actually not super helpful. So it's important to know that cortisol is not the villain for most obesity or diabetes. When it's actually Cushing syndrome, the body tells a much more specific story than weight gain. Myth number five, everyone on chronic steroids needs maximal stress dose steroids for any procedure This is more of an inside medicine myth, but it matters if you or someone you love is on long-term steroids heading into surgery for a procedure. The old rule was that we gave everyone steroid, on steroids a huge stress dose before any procedure, and we've actually replaced it with what's called a tiered approach based on how stressful the procedure actually is. So for if someone you love has adrenal insufficiency, for minor procedures or minor stress, like you're having something done under a local anesthesia and you're already on a reasonable steroid dose, some people actually don't need an increase at all unless they start having their blood pressure drop or other crazy things happen. For people who are undergoing major surgery, like general anesthesia, then in that case, we will usually give a hundred milligrams of a steroid called hydrocortisone at the start of the procedure, and then they get a continuous infusion and then additional doses after that we then taper down to their home dose. And giving everyone the highest dose of steroids, just in case, isn't protective. It actually exposes people to real risks of taking too much steroid, which are gonna be high blood sugars, poor wound healing, infection, mood changes. And so more steroids are not automatically safer. The goal is really to match what's happening in the body and not just flood the system with steroids in the name of keeping people safe. Now, myth number six is that adrenal insufficiency is easy to diagnose clinically. Of everything in this episode, this is the myth I want you to walk away with remembering because the cost of it isn't a wasted supplement purchase. It's years of suffering and sometimes a medical emergency. But a quick reset before we go any further. This myth is not about adrenal fatigue. That's the fake one from myth one. This is about adrenal insufficiency, which is a real diagnosable disease where the adrenal glands genuinely don't make enough cortisol, and it's life-threatening. The same gland, completely different framework, and the myth is that it's obvious when someone has it, and it isn't obvious when somebody has adrenal insufficiency, at least not initially. True adrenal insufficiency is frequently missed for months to years because the symptoms mimic the symptoms of other conditions. A lot of patients will present with fatigue, nausea, weight loss, joint pain, and that overlaps with, like, a dozen other common conditions. And in one cross-sectional study that was done, It was noted that twenty percent of patients had symptoms for more than five years before they were diagnosed with adrenal insufficiency. Fewer than thirty percent of women were diagnosed within six months of when the symptoms actually started. And up to half of the patients diagnosed with adrenal insufficiency experienced a life-threatening adrenal crisis either right before or shortly after they were finally diagnosed, meaning the delay itself is dangerous and not just frustrating. Adrenal crisis is really scary. I've admitted patients in adrenal crisis. Their blood pressure is tanking. They're having nausea and vomiting. They're not able to maintain their blood pressure. They are passing out. It can be very, very scary. And a lot of times what happens is they will be going along, and then they have some major stressor happen, like an illness or a surgery or, they get into a car accident, and their adrenal glands are not able to make enough steroid to get them through that crisis. And so it puts the body itself into crisis. Here's the connection back to where we started, adrenal fatigue, which was the first myth, and a true diagnosis of adrenal insufficiency are not the same condition, even though they kind of sound like they would be cousins. One is a wellness industry myth that has no test, no mechanism, and no diagnosis behind it, and the other one is a real measurable and sometimes life-threatening disease of the adrenal gland itself, And it's the one unfortunately that we are worse at catching in time. And here's the part that should actually bother you. The noise around the fake diagnosis may be making it harder to catch the real one. The phrase, "I think it's my adrenals," has been the battle cry of the supplement industry that make both patients and clinicians mentally file it under like wellness chatter instead of running the actual tests that would tell you and give you a diagnosis. So if you've been told to support your adrenal glands for a few years and nothing's changed, that's not a sign that you need a stronger supplement. It's a sign you need a better workup. As we close out this episode of the six myths, let's run it back real fast. Number one, adrenal fatigue isn't a diagnosis. Number two, adrenal support supplements are not harmless. Number three, most incidentally found adrenal tumors, otherwise known as adrenal incidentalomas, don't need surgery. Number four most people with obesity and diabetes don't need Cushing screening. Number five, most people on chronic steroids don't need to be put on huge stress doses for every procedure they have. And number six, real adrenal insufficiency is dangerously underdiagnosed, partly because the fake diagnosis of adrenal fatigue takes up all the attention, and it's so much louder than the real one. If this episode made you rethink something about your own health or something you were told by a wellness account with very good lighting, that's exactly the point of this series. If you know someone who's been told to, quote, "heal their adrenals" with a $90 supplement bundle, send them this episode instead. Follow the show, leave a rating, and find me on socials, @drpatilsisodia, And if you've got 30 seconds, pop over to my website, clearlyhormonal.com, where you can find the full reference list from today's episode on the show notes, and let me know if you have more questions. My next episode in this series is going to focus on how you test for true adrenal insufficiency and what fake tests are out there that are really just taking money out of patients' pockets. Thank you so much for tuning in, and I will see you on the next episode.