Discussions that mention florinef

Thyroid Disorders board

Adrenal Fatigue

This is meant to be as much a request for comment from those individuals who have been through and recovered from adrenal fatigue, as is it a compilation for others to read.

I am not yet convinced of the credibility of the adrenal fatigue concept, nor do I have specific knowledge discrediting it. I have talked with several Doctors who subscribe to the theory, several who do not, and several who are just not sure one way or the other.

To over-simplify the theory, whenever you have a situation that requires above normal output of adrenal hormones (esp. cortisol and adrenalin), ACTH rises and commands the adrenal glands to produce more of these hormones (ACTH is to adrenals as TSH is to thyroid).This is ok on occasion. However when it's a long-term and constant situation, the adrenal glands can become exhausted and stop functioning fully as before. Such a situation is untreated hypothyroidism.

Symptoms of adrenal fatigue include, blood pressure that drops when you stand up, and exercise intolerance (where you exercise, but don't seem to recover quickly – maybe over a couple of days even), slow recovery from colds and any inflammatory condition. Additionally, with hypothyroidism a common symptom is the inability to tolerate a level of thyroid medication high enough to alleviate hypothyroid symptoms (usually, heart palpitations, insomnia, nervousness, anxiety).

Cortisol (actually the lack of) is the main adrenal hormone seen as responsible for the symptoms of adrenal fatigue. Cortisol is normally secreted in what is known as the circadian rhythm, where most of your daily allotment is secreted in the early morning, less during the day, and still less at night, unless stress, illness, surgery, or something like hypothyroidism commands more. This rhythm is important to understand. The amount of cortisol typically present in your blood at any point in time during the early morning hours (6-8 am) is three times that at mid-day, and eight to twelve times that at night.

Common misconceptions in testing are the single blood draw for cortisol, or the 24 hour urine collection method. Both are useful for other means, but flawed for diagnosing adrenal fatigue because they either test one point in the day (the single blood draw), or average the cortisol over one entire day (the 24 hour urine collection).

It is common with adrenal fatigue to have near-normal cortisol levels at certain points in the day, yet be lacking at other points. In fact, depending on what stage in the disorder you are, some points in the day can have above-normal levels, yet still other points below-normal.

The testing method universally accepted by those Doctors who do subscribe to the adrenal fatigue theory, is the fours points per day saliva test. You simply spit into a tube at four timed points in one day, and mail those off to the lab. The result is that you will see how your cortisol levels are through the day. Note that some Doctors question the correlation of saliva to blood levels.

For example, my results six months ago:
Morning ( 6:00 - 8:00 am) 17.5 nM ( 12.0 – 24.0 )
Noon ( 12:00 – 1:00 pm ) 6.1 nM ( 5.0 – 8.0 )
Afternoon ( 4:00 – 5:00 pm ) 3.8 nM ( 4.0 – 7.0 )
Nighttime ( 10:00 pm – 12:00 am ) 2.4 nM ( 1.0 – 3.0 )
Cortisol sum 29.8 nM (23.0 – 42.0 )
DHEA-S average 2.14 ng/ml ( 2.00 – 10.00 )

Not really that bad – and improved a bit from one year earlier.

To further test, I had what is called the ACTH stimulation test, where you are injected with extra ACTH, and if everything goes well, your adrenal glands should wake up and secrete a lot more cortisol. Cortisol is tested before the injection, and then 30 and 60 minutes afterward.

My results from one year ago, 8:00 am, for example:
Baseline serum free cortisol 1.48 ug/dl ( 0.40 – 1.93 )
Baseline plasma ACTH 29 pg/ml (7 – 50 )
30 minutes post injection 4.10
60 minutes post injection 4.07 ( 1.88 – 4.73 )

In my case, I would call this either inconclusive for adrenal fatigue, or conclusive against.

If you do have adrenal fatigue, the treatment it so take some cortisol medication daily, to make up the difference, and to give your tired adrenal glands time to recover. This generally takes from several months to one or two years. Then you slowly taper off, with your adrenal glands filling in as they should normally do. Doseage starts low, and usually does not exceeded a physiologic does, that is, the amount your body would normally produce on it's own. The medication of choice is usually Cortef, a brand of hydrocortisone. In some cases Florinef is added.

The complications are several-fold:
1. Taking hydrocortisone will lessen your hypothalamus' production of ACTH, and in turn, lessen the activity of your adrenal glands. That's what you are going for, but that can, over time atrophy the adrenal glands. It is possible that the adrenal glands will not startup properly, once you discontinue the meds.
2. Taking hydrocortisone, depending on the amount, will effectively shut down your adrenal glands. You will not have the usual up and down reaction to illness, stress, lack of sleep, etc. that the Adrenal axis usually compensates for without your knowledge. Any increase in your body's use of cortisol, will result in depleting your body of cortisol, which can be life threatening, unless you sense that as it is happening, and quickly take more meds to compensate, just as your adrenal glands would normally do, before you shut them down with the meds.
3. Exogenous cotrisol can lead to diabetes (heard that somewhere – true/false?)
4. Hydrocortisone is a steroid. Weight gain, and the whole host of usual possibilities can result.

Now, in my case, I have been unable to exercise at all for the past four years. I was an athlete before-hand, and unbeknown to me, was undiagnosed hypothyroid. One day, after bicycling 20 miles, I became more tired than usual, and could barely stand a few days later. That brought a hypothyroid diagnosis, and I started thyroid meds. My inability to exercise made me suspect adrenals.

Also, last fall, I got a bad case of poison ivy. The Doc gave me a hydrocortisone shot and followed that with dexamethasone meds. Within a day I suddenly was out biking again. However that was short lived, as I got very tired a day later, and stayed there. It seemed I had a hard time restarting after the taper-off of meds too.

So that's a compilation of what I've picked up along the way. No endorsements of any of the above one way or the other. I don't know what's true and what isn't. Even the Doctors differ wildly. If this helps anyone with what to go look up, great. What would be interesting though, is if Deb123 or anyone with such experience could comment on my particular case.
My advice to you is to find another doctor who will listen. Deb is right, and has been there for me many times. You can take all the thyroid meds out there, and it will do you no good if the adrenals aren't functioning. Like Deb I felt like a part of myself had died until they got my levels of cortef and florinef right. I could not move, get up, participate in life, much less pay attention, or feel like being an active participant in my life. I had thyroid cancer that was undetected for a year and a half, and it is believed that all of this is correlated with the adrenals. When I first started cortef and florinef, I too had a burst of energy. I could have mowed lawns for the neighborhood, and I did a lot in the two days it lasted, and I crashed. I had a huge setback for several days. It was then determined my dosage was not near enough. I just know that I now have my life back, and a few weeks ago they tried lowering it.
It was not enough, and I was almost back to square one. It was increased again, and now I am fine.
Research doctors in your area, ask around on who is the best one to help you with your problems. A good endocrinologist is a MUST. If at first you don't find one who will listen, find another.

I will keep you in my prayers. I TOTALLY KNOW HOW YOU FEEL.
Thanks kmatthew, So it seems a similar situation.

The evidence I have thus far is:
1. My symptoms are consistent with the AF theory.
2. One day of feeling suddenly perfectly normal due to either:
a. Poison Ivy (doubt it)
b. Hydrocortisone injection.

The evidence disputing that is the ACTH stimulation test that shows very good ability of my adrenal glands to respond to ACTH.

I state it that way, because what we don't know is whether or not my HPA axis is sending the right signals CRF/ACTH.

The HC route seems like something to try, but it's so risky, right? That whole stress dosing situation really concerns me. So does the atrophy possibility

What has been your experience? Do you know of people who have gone this course, gotten off the HC and recovered?

Any, I forget, what is the Florinef for?
Florinef is to help you maintain your blood pressure when sitting and standing etc. It has been a must for me.
The riskiness of hydrocortisone is worth it to me because I know how I feel without it. I cannot make it without it. I turn into a 90 year old instead of a 37 year old, and I can't even function at all without help. Adrenal Insufficency is not something to mess around with, it can be life threatening if you are not producing the cortisol that you should.
For me the medication was not an option. I went to work perfectly normal one day, and came down a flight a stairs and don't remember a thing. I ended up in a hospital room with franctic family members and an Endocrinologist who was determined to find out what happened to me. You are fortunate that you have a choice on if you would like to be medicated or not. I can say that I am not sorryI am on these drugs. I do worry about the long term effects, but what was explained to me is that I am not making cortisol, so these drugs are putting there what I need. You will feel so much better.
I hope that you find the answers that you need.
So the saga continues ....

Before I start Cortef, I want to rule out hypopituitary problems, and to also determine if I will also need Florinef. They way this is done, as I'm told, is to be off HC for two weeks, limit salt for one day, then test Aldosterone and Renin.

So I did that, but the lab didn't handle the freezing of the Renin test sample properly, so I have to repeat that blood test tomorrow morning.

Just though I'd keep this thread updating, since so many people commented on it being helpful to watch.

I'm still apprehensive about going down this road. I'll keep updating to document the journey.