NB! Jeg har oversatt teksten til norsk lenger ned i tråden.


2. DIAGNOSTISERING

Jeg siterer videre fra Mary Shomons bok:


- Evaluating Adrenal Fatigue (s. 244-245)

Conventional endocrinologists and tests cannot diagnose adrenal fatigue because they are prepared only to diagnose extreme dysfunction in the adrenals, such as Addison's disease, a potentially fatal condition where the adrenals essentially shut down.

Your holistic or integrative practitioner, however, can do a number of tests to evaluate your adrenal function, and diagnose adrenal fatigue or other subtle dysfunctions in your adrenal glands. These tests include:

  • - 24-hour urine test, looking at multiple samples over 24 hours
    - Saliva testing for cortisol levels, usually done at several points over a 24-hour period
    - DHEA - since DHEA is a precursor to almost all the other adrenal hormones, low DHEA levels can often signal adrenal fatigue
    - Pregnenolone, like DHEA, is a precursor to adrenal hormones. Blood and saliva testing of pregnenolone may provide information on low adrenal function


Dr. Kate Lemmerman tests adrenal function in her hypothyroid patients and frequently finds signs of adrenal stress, often with low DHEA-sulfate levels. Says Lemmerman:
Often if patients are still fatigued after having idealized their thyroid functioning with appropriate thyroid replacement I find that their DHEA-S levels are less than ideal and their fatigue can be ameliorated with supplementation. I use DHEA-S levels rather than serum DHEA as I find that, as the sulfonated molecule is the active version, it is like testing for Free T-3, rather than total T-3.
Dr. Kent Holtorf typically diagnoses adrenal insufficiency using a combination of symptoms, plus blood sugar, free cortisol, and hemoglobin A1C testing. Says Holtorf:
One must have a high clinical suspicion and not just think in terms of normal and abnormal. These normal levels are determined for healthy individuals, not the chronically ill, so the cortisol levels should be higher with this illness. 24-hour urine and saliva tests can be done, but these can also result in false positive and false negative results. Some doctors who treat these disorders have reported that cortisol is not helpful; this is totally opposite to my experience. I have found this adrenal hormone to be very helpful.


--------------

Fra Shames' bok:

How to Determine If You Are Low Adrenal (s. 141-147)
It would be wonderful to have a simple, reliable method of assessing a person's adrenal function. Many tests are available but none is widely used. One reason is that most medical doctors consider that the adrenal system is always functioning smoothly, except in two very severe and rare circumstances. One is caused by overproduction of cortisol called Cushing's Syndrome. Underproduction of cortisol is called Addison's Disease. When it is clear to a physician that you do not have either Cushing's or Addison's, the topic of adrenal metabolism all too often is shoved aside.

(...), normal adrenal metabolism is essential to good health, and problems can arise even when you do not have either of these two rare illnesses. The truth may well be that there is a continuum between these two extremes. Problems may occur at various points along this spectrum of adrenal dysfunction, rather than as rare illnesses that occur only at either extreme. (Ref: A. Kasperlik-Zaluska, "High Prevalence of Thyroid Autoimmunity in Idiopathic Addison's Disease", Autoimmunity 18, no. 3 (1994): 213-216.)

Why Aren't Adrenal Tests Ordered More Often?
Another reason doctors may not be sufficiently involved in this topic is that adrenal tests are even more challenging to interpret than thyroid tests. The biochemistry is extremely complex and, until recently, the testing technology had not been widely useful except to diagnose Cushing's and Addison's. Now the measurements are more sophisticated. Current technology can be divided into roughly two camps: conventional medical evaluation; and the more recently developed alternative adrenal tests.

What Are the Standard Options?
The conventional medical evaluation for adrenal function includes measurements of ACTH (adrenocorticotropic hormone) from the pituitary, as well as cortisol (hydrocortisone) from the adrenal glands themselves. Both of these are simple blood tests.

In addition, doctors will sometimes obtain a 24-hour urine sample for cortisol and related cortex hormones. (...) One drawback with this measurement is that it is not illustrative of variations within the 24-hour period, because the whole day's worth of urine is mixed together in one bottle. The level of adrenal hormone is naturally high in the morning, progressively diminishes through the afternoon, and reaches its lowest levels in the evening. In the case of the 24-hour urine sample, the doctor can determine if the total amount of hormone is high or low for the whole day, but will not know at what time of day major variations occured. (...)

In much the same manner, a blood cortisol level is meaningless by itself. You need to know what time of day the sample was taken. Thus, the patient's blood is drawn at a standard time of day, when there is a large sample of normal values for comparison. (...)

Complicating this test is the fact that the blood cortisol level is dependent on the red blood cell protein molecules that carry it in the bloodstream. The amount of this protein carrier can change for a variety of reasons, which changes the level of cortisol that is measured. Abnormal estrogen levels and liver trouble also can lower the amount of this carrier protein, which will alter your test result. In addition to all this, one's level of activity can change the result of the test. Moreover, commonly used blood tests do not distinguish between protein-bound cortisol, and the unbound free form, which is more readily bioavailable. The new test for free cortisol is clearly preferable.

Stress level has a significant impact, too. Someone may have rushed to get to the lab or come from a stressful meeting at work. That would yield a different level than that of a patient who was calmly sitting in the waiting room for half an hour before the test. In addition, the conventional tests have a normal range that is very wide, so that only the most severe, out-of-range abnormalities qualify as being diagnostic of abnormal adrenal function (sound familiar?).

For these reasons, many doctors do not order adrenal tests at all. If they do, they generally focus not on cortisol, but on evaluating adrenaline levels (...). Since adrenaline and its related compounds are known as catecholamines, testing for levels of adrenaline is also known as testing for catecholamines. It was once thought that a person who was overly stressed would display very high levels of these compounds. But the tests are hard to interpret. The phase of adrenal depletion might be adaptive (high levels), or exhaustive (low levels).

In addition, just as with the cortisol tests, the time of day, the patient's level of activity, and the exact timing of the samples during a 24-hour period have sometimes proved to be daunting to the lab, the patient, and the doctor interpreting the test. Even low blood sugar triggers catecholamine release. The same difficulties for measuring 24-hours' worth of urinary adrenal cortex hormones would apply to measuring 24 hours worth of urinary catecholamines.

The evaluation of primary adrenal insufficiency, therefore, is best performed by giving the person a medication to stimulate the release of cortisol. The goal of this type of "challenge testing" is to measure adrenal reserve. Long before a failing adrenal gland reveals definite abnormal levels of hormone, it will go through a period of low reserve.

The way to determine the amount of adrenal reserve is to measure gland output after ACTH stimulation. The adrenal is stimulated into increased production with a quarter milligram of Cortrosyn (or some other synthetic version of ACTH), given by injection. The baseline blood cortisol is measured just prior to this injection, and the increased result is measured at the end of an hour. We believe that an increase of less than 10 micrograms, or a peak result of less than 25 micrograms, is a lowered response, thus indicating an inadequate adrenal reserve. There is not full agreement among the experts, however, about proper interpretation of either the incremental increase or the peak result.

This complicated stimulation test is much more expensive and invasive than an ordinary blood test. Moreover, it still may not tell us much at all about mild adrenal insufficiency, which could be affecting your thyroid hormone function.

Are the Alternative Options Any Better?
If conventional medicine is stymied by the adrenal system's subtleties, what do the alternative practitioners have to offer? They have chosen laboratories that try to assess adrenal function somewhat differently. A number of labs will do urinary measurements as described above, but instead of using 24-hour's worth of urine, they use four separate samples collected at (08.00), (12.00), (16.00), and midnight. Testing four different samples taken throughout the day is an attempt to obtain a more complete adrenal profile than one sample would provide. This allows a more detailed picture of the patient's daily cyclic adrenal function, and better distinguishes between the alarm phase and the exhaustion phase.

In addition to increased determinations per day, the new test measures more than cortisol levels. Also commonly tested is DHEA, a precursor to some of the other adrenal hormones. (...) The resulting set of numbers, which some labs call the Adrenal Stress Index or ASI, can then be used to initiate and monitor therapy.

Saliva measurement is another type of test not yet considered part of a conventional adrenal workup. The determination of hormonal levels in saliva is, however, being researched for its effectiveness in assessing glandular health and balance. (Ref: M. Laudat et al., "Salivary Cortisol Measurement: A Practical Approach to Assess Pituitary-Adrenal Function", Journal of Clinical Endocrinology and Metabolism 66, no. 2 (1988): 343.) One such saliva test is similar to the urinary ASI above. It tests four saliva samples, collected at four specific times of day (...). Like the urinary tests just mentioned, more than cortisol levels are measured. Some saliva labs will check cortisol, DHEA, and pregnenolone. Pregnenolone, like DHEA, is a chemical precursor to many of the important adrenal hormones. The saliva measurement is a good choice because of its ease of collection and affordability, but its degree of reliability remains to be fully evaluated. It is potentially much more accurate than blood testing, because saliva tests measure only the free (bioavailable) form of the hormone.




TEST DEG SELV!

(Fra Shames' bok - "A Self-Assessment" (s. 149-150).)


To explore whether there might be an adrenal component to your low thyroid function, ask yourself the following questions.

Do you have:
  • - Low stamina for stress, easy irritability?
    - Excess mood responses after eating carbohydrates such as pasta, breads, and sugars, or marked low blood sugar or hypoglycemia?
    - Chronic infections (bacterial, viral, fungal, or yeast)?
    - Low blood pressure, fainting, or feeling of momentary light-headedness upon standing up?
    - Chronic allergy/sensitivity to common items in environment?
    - Arthritis or other chronic inflammatory response?
    - "Tired but wired" feeling? Poor sleep?
    - Having your best energy when others are winding down and sleeping?
    - Cravings for sweets, intolerance to alcohol?
    - Especially poor resistance to respiratory infections (getting them more often and being depleted when you have them)?
    - Dry unhealthy skin with excess pigmentation?
    - Cystic breasts (chronic cystic mastitis)?
    - Difficulty recuperating from jet lag?
    - Significant anxiety with depression?
    - A sense of aging prematurely?


If you answered yes to four or more of these, and if you have experienced some of the difficulties outlined in this chapter, you might want to consider adrenal testing to evaluate your condition further.



----------------------------

Videre fra artikkelen til dr. Durrant-Peatfield:


If a high index of suspicion of adrenal insufficiency is raised by the history given by the patient, then what are the signs the doctor looks for 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 quite low, often very strikingly so. The difference between the lying, (or sitting) blood pressure, and the standing one, may be very important. Normally, it rises when the patient stands. In low adrenal reserve, it either does not change at all, or lowers further. The pupil reflex is slow, or unstable, or even reversed, to bright light. Reflexes may be abnormal, especially the Achilles reflex -- in the heel. The heart sound is characteristically altered.

It is satisfactory to confirm the clinical impression by blood tests; but these sometimes are unhelpful. The level of cortisone in the blood may be measured, but it is widely variable. However, DHEA, mentioned above, is quite a good indicator of adrenal cortex function. The urinary excretion of adrenal hormones is an excellent indicator -- but the practical problems, (it has to be over 24 hours), and the expense of really good laboratory analysis, tend to limit this test to hospital in-patients.

It is, in our view, perfectly practical and reasonable, to establish the diagnosis on clinical grounds, and because the therapy given is of very low -- physiological -- doses, there is no possible risk to the patient, however long it is needed. In a very large number of cases, the adrenal insufficiency may right itself over two or three months, making further supplementation unnecessary.