The use of adrenal hormones needs to be put into perspective, however. Imagine if early thyroid researchers had given their patients fifty times the usual dose of thyroid hormone. Thyroid patients would have routinely died of heart attacks. The thyroid researchers, though, were fortunate enough to stumble upon the healthy dose early on and to skip negative outcomes (likely because too high a dose of thyroid caused immediate side effects). If they had not, people today would not be treated for an underactive thyroid until they displayed symptoms of advanced thyroid disease (myxedema) and were nearly comatose. Medical science is just beginning to learn that a person can feel horrible and function poorly even with a minimal to moderate hormone deficiency. Waiting for the person to “go off the deep end” of the test’s normal scale is simply not healthy.
Dr. Jefferies has found that as long as the adrenal hormone level does not exceed the normal range, the main toxicity that a patient might experience is a slight upset stomach, as the body is not used to absorbing the hormone through the stomach.11, 50 If this occurs, taking the hormone with food usually helps. In addition, some patients gain a few pounds. This is because a low adrenal level can cause a person’s weight to drop below the body’s normal set point, even if that set point is high because of CFS/FMS. However, any weight gain usually is more than offset by the eventual weight loss resulting from being able to exercise and function once again.
As discussed, many physicians do not like to prescribe even low doses of adrenal hormones. If your doctor is uncomfortable with hydrocortisone (Cortef, the natural and safer form of the adrenal hormone), and natural remedies do not provide sufficient relief, invite him or her to read Dr. Jefferies’s material on the safety of low-dose cortisone as well as our study, which is available on my Web site (www.vitality101.com).11, 50
Additionally, the NIH Institute of Allergy and Infectious Diseases showed that what they called “low-dose” Cortef (25 to 35 milligrams a day) moderately helped CFS patients but caused some patients’ adrenal glands to “go to sleep.”51 This is a concern, but as noted in my letter to the editor printed in the Journal of the American Medical Association, the dose used in the NIH study was two to three times as high as most CFS patients need and therefore dramatically worsened the sleep disorder.52 Another study (using 10 milligrams of Cortef a day in CFIDS) and studies of CFS/FMS patients show significant benefit using lower doses without significant toxicity. 4, 11, 53 Indeed, most patients only need 5 to 12.5 milligrams a day—a dose lower than most doctors have ever prescribed. This dosage is equivalent to 1 to 3 milligrams a day of prednisone, which is the more toxic synthetic adrenal hormone used by most physicians. However, Cortef is better than prednisone for people with CFS/FMS, as it is bioidentical and more closely mimics your body’s own hormonal activity. After feeling well for six to eighteen months, most people are able to begin slowly decreasing their adrenal hormone dosage, eventually discontinuing the treatment entirely as their adrenal glands resume normal function.
Our studies and clinical experience show that ultra-low-dose cortisol is unlikely to cause adrenal suppression, and this conclusion has been supported by other research. In a study published in 2001 in Journal of Clinical Endocrinology & Metabolism, the authors checked adrenal function in thirty-seven patients with CFS and then treated these patients with low-dose cortisol. They found that the treatment resulted in significant improvement and not only was there no adrenal suppression, but rather there was an improvement in the HPA axis function. They concluded: “In this group, there was a significant increase in the cortisol response to human CRH, which reversed the previously observed blunted responses seen in these patients. We conclude that the improvement in fatigue seen in some patients with chronic fatigue syndrome during hydrocortisone (cortisol) treatment is accompanied by a reversal of the blunted cortisol responses to human CRH.”54
The safety of low-dose cortisol was also addressed in a forty-eight-page review article published in the Annals of Rheumatic Diseases. This extensive review assessed the safety of long-term low-dose glucocorticoid (cortisol) therapy in rheumatoid arthritis, considering “low dose” to be 40 milligrams hydrocortisone (much higher than the 10 to 20 milligrams we recommend). The researchers concluded: “Adverse effects of glucocorticoids are abundantly referred to in literature. However, in the available literature on low-dose glucocorticoid therapy very little of the commonly held beliefs about the incidence, prevalence, and impact of GC [glucocorticoids] proved to be supported by clear scientific evidence. Additional data from the randomized controlled clinical trials reviewed showed that the incidence, severity, and impact of adverse effects of low-dose glucocorticoid therapy in rheumatoid arthritis trials are modest, and often not statistically different to those of placebo.”55 This considerable safety and negligible risk is also confirmed in endocrinology texts.56
Recently, studies have been published about bone loss with the use of low-dose adrenal hormones, but even these studies do not use the very low doses that we use.57 Nonetheless, it is reasonable to take bioidentical estrogen (that is, estrogen identical to what our bodies make) if you are a menopausal or estrogen-deficient female. If you have low bone density, also take 600 to 1,500 milligrams of calcium a day, 340 milligrams of strontium (more effective than Fosamax), and 600 to 4,000 units of vitamin D daily (see Chapter 8). You can also get your calcium by adding two cups of yogurt with live and active yogurt cultures to your daily diet. Your doctor can guide you further on your calcium needs.
ADRENAL FUNCTION AND BLOOD PRESSURE
Another important function of the adrenal glands is maintaining blood volume and pressure by keeping salt in your body. Low blood pressure, low blood volume, and dehydration are common in CFS patients. In adults with CFS/FMS, I have found dextroamphetamine (Dexedrine) and the antidepressant fluoxetine (Prozac) to reverse the dizziness and low blood pressure of neurally mediated hypotension (NMH).58–61 In fact, antidepressants have actually been proven to increase exercise performance in CFS/FMS.62 I would also note that Dexedrine and Ritalin, which I believe are overused in ADHD and underused in CFS/FMS, are helpful in CFS/ FMS and have been shown in a placebo-controlled study to also help both fatigue and concentration in these syndromes.63 A medication called ProAmatine (midodrine) may also be helpful occasionally. It is critical to begin with the basics, however, which includes drinking plenty of water and getting enough salt and potassium.
Though not helpful in adults, a salt-and water-retaining adrenal hormone called Florinef can be of benefit for those under age twenty-two. Young people can take one-quarter of a 0.1-milligram tablet per day and increase by a quarter tablet every four to seven days until they reach one whole tablet. Effects may not be evident for three to six weeks. An even simpler treatment may be to simply increase the intake of salt. In fact, Dr. David Bell, a physician specializing in pediatric CFS, found that nineteen of his twenty-five CFS patients felt much better when they received a quart of salt water (normal saline) intravenously each day.
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Getting Kids and Young Adults Well—Information for Patients Under Age Sixteen
If you’re under age sixteen, you most likely have neurally mediated hypotension (NMH)—sort of like low blood pressure—and an allergy to milk proteins. Some doctors do a type of test called the tilt-table test to diagnose NMH, but I treat NMH without doing the test first. It’s not a bad idea to have it done, but it is expensive and uncomfortable.
To treat NMH, your doctor can prescribe the medications fluoxetine (Prozac), midodrine (ProAmatine), fludrocortisone (Florinef, which is modestly effective), and/or methylphenidate (Ritalin) or dextroamphetamine (Dexedrine). Of all of these, Dexedrine and Ritalin are most helpful for those under twenty years of age. In addition, the following things can be helpful:
Avoid sugar. Stevia is a healthy sweetener you can use instead.
Take the Energy Revitalization System vitamin powder or a similar multivitamin supplement.
Dramatically increase your intake of salt
and water. Aim for 8 to 15 grams of salt and one gallon of water each day.
If you have stomach or bowel symptoms, cut out all milk products and any foods containing casein or caseinate (milk protein) for two to three weeks to see if this helps.
If you have taken a lot of antibiotics and/or steroid medications (cortisone, prednisone, or others), ask your doctor to consider treating you with natural antifungals for five months and fluconazole (Diflucan) for six to twelve weeks to get rid of possible yeast overgrowth (see Chapter 5).
If you run frequent fevers (temperatures over 98.8°F), you likely have a hidden infection. A three-to-six month trial of antibiotics should be considered (see Chapter 5). In addition, get a parasite test done by a laboratory that specializes in this type of testing, such as the Parasitology Center or the Genova/Great Smokies Diagnostic Laboratory (see Appendix E: Resources).
Consider thyroid treatment with Cytomel (see Chapter 4).
If you’re not better, then refer to the rest of the program outlined in this book. Chapter 5 offers more detailed information on treating infections.
Fortunately, these simple suggestions help most kids get better.
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To summarize, if your symptoms started suddenly after a viral infection, if you suffer from hypoglycemia (and irritability when hungry), or if you have recurrent infections that take a long time to resolve, you probably have underactive adrenal glands. About two-thirds of my severe chronic fatigue patients have underactive or marginally functioning adrenal glands or a decreased adrenal reserve.
Although I prefer natural products to pharmaceuticals, in this situation I am comfortable adding standardized bioidentical hormones to the natural therapies. By using these natural remedies in conjunction with Cortef, you may need a lower dose of the bioidentical hormone than you would otherwise. And you may be able to stop the cortisol supplementation sooner by helping your adrenal glands and hypothalamus heal. If the amount of hormone given is within the body’s normal range, the body can decide for itself how much of the hormone it wants to use, making these treatments very safe.
DEHYDROEPIANDROSTERONE (DHEA)
The adrenal glands make many hormones in addition to cortisol. One of these is DHEA, which is often low in CFIDS patients. Although DHEA’s function is not yet fully understood, it appears to be important for good health, which makes a low DHEA level worth treating.64–66 For many CFS/FMS patients, when a low DHEA level is treated, the result is a dramatic boost in energy. Some studies suggest that the higher a person’s DHEA level is, the longer that person will live and the healthier he or she will be. However, I’m concerned that pushing the blood level above the upper limit of normal may increase the risk of breast cancer, so you should work with your doctor to be sure blood DHEA-S levels do not exceed a safe limit.
If your DHEA sulfate (DHEA-S, not DHEA) level is low (under 120 micrograms per deciliter [mcg/dL] of blood for females or 325 mcg/dL for males), I recommend beginning treatment with 5–25 milligrams of DHEA per day and slowly working up to what feels like an optimal level to you. For women, I suggest keeping the DHEA-S level at around 150–180 mcg/ dL, which is the middle of the normal range for a twenty-nine-year-old female. For men, I keep the DHEA-S level between 350 and 500 mcg/dL, which is the normal range for a twenty-nine-year-old male. The low ends of the normal ranges are normal only for people over eighty. If you have side effects, such as facial hair or acne, which are uncommon, check your blood level of DHEA-S and decrease your dose. A good form of DHEA (some are not) is available without a prescription at compounding pharmacies, my Web site, and the General Nutrition Centers.
We have found that roughly 10 percent of women with CFS/FMS actually have an elevated DHEA-S level. This is often associated with an elevated testosterone level as well. When I see this, I suspect and look for polycystic ovarian syndrome (PCOS) and insulin resistance. If a fasting morning insulin level is higher than 10 (suggestive of insulin resistance), especially if ovarian cysts or infertility are also present, these patients often improve significantly with a diabetes medication called metformin, 500 to 1,000 milligrams one to two times a day, which improves insulin sensitivity. This can also assist with restoring fertility, as well as helping the patient lose excess weight. As metformin can cause vitamin B12 deficiency, it is critical that a high-dose B12 supplement be taken with it. Polycystic ovarian syndrome may also improve with low-dose hydrocortisone and with chromium supplementation of 1,000 micrograms daily.67
The Thyroid Gland
The thyroid gland, located in the neck area, is the body’s gas pedal. It regulates the body’s metabolic speed. If the thyroid gland produces insufficient amounts of thyroid hormones, the metabolism decreases and the person gains weight. Other symptoms of hypothyroidism include intolerance to cold, fatigue, achiness, confusion, and constipation (though diarrhea from bowel infections is common in CFS/FMS).
The thyroid makes two primary hormones. They are:
Thyroxine (T4). T4 is the storage form of thyroid hormone. The body uses it to make triiodothyronine (T3), the active form of thyroid hormone. Most synthetic thyroid medications, such as Synthroid and Levothroid, are pure T4. These synthetics are fine if your body has the ability to properly turn them into T3. Unfortunately, many people with CFS/FMS find that their bodies do not have this ability.
Triiodothyronine (T3). T3 is the active form of thyroid hormone. Although in some life-threatening illnesses the body appropriately makes less T3, research suggests that when CFS/FMS occurs, the body may not be able to adequately turn T4 into T3, or it may need much higher levels of T3.
THE PROBLEM WITH THYROID TESTS
Many years ago, while I was in medical school, physicians were taught to diagnose hypothyroidism, or low thyroid function, by using the newly discovered method of measuring the metabolic rate while the patient ran on a treadmill. We doctors thought that this was a wonderful new test and that we finally had a way to identify patients with underactive thyroids. We congratulated ourselves on being so clever. But then a new test came out. The new test measured protein-bound iodide (PBI). When we began using the PBI test, we realized that we had missed diagnosing many people with a low thyroid, but thought that this new test would pick up everybody who had a problem. We patted ourselves on the back and told all our newly discovered thyroid patients that it turned out that they were not crazy—they just had a low thyroid. We were comfortable that we could now determine with certainty when someone had a thyroid problem.
Then the T4-level thyroid test was developed, and we thought that the old PBI test had missed many people with a low thyroid, but this new test would find everyone. Then the T7 test, which adjusts for protein binding of thyroid hormone, came out, and then the thyroid-stimulating hormone (TSH) test. Modern medicine is now beyond the fifth generation of TSH tests, and this is the only test that many doctors use to monitor thyroid function. With each new test, doctors realize that they missed many people with underactive thyroid function. In 2002, the American Academy of Clinical Endocrinologists noted that anybody with a TSH under 3 should be treated for hypothyroidism, and that 13 million Americans had an underactive thyroid that was not being treated because labs were being misinterpreted. Despite this, most labs still have a normal range for TSH that goes up to 5.5. To make matters more difficult, if the thyroid is underactive because the hypothalamus is suppressed, the TSH test, which depends on normal hypothalamic function to be at all reliable, may appear to be normal, or may even suggest an overactive thyroid. In fact, when lecturing at a fibromyalgia conference in Italy, I spoke with Professor Gunther Neeck—the world’s foremost expert on hypothalamicthyroid axis dysfunction in fibromyalgia.8 I asked him a simple question: “Is the TSH test reliable in fibromyalgia?” He gave a very simple answer: “Absolutely not!” Fortunately some doctors are finally starting to catch on.
In two studies done by Dr. G. R. Skinner and his associates in the United Kingdom, patients who were felt to have hypothyroidism (an underactive thyro
id) because of their symptoms had their blood levels of thyroid hormone checked. The vast majority of them had technically normal thyroid blood tests. These data were published in the British Medical Journal.68 He then did another study in which the patients with normal blood tests who had symptoms of an underactive thyroid—those whose doctors would likely say had a normal thyroid and would not need treatment—were treated with thyroid hormone. A remarkable thing happened when this was done (well, maybe we’re not surprised). The large majority of patients, despite being considered to have a normal thyroid, had their symptoms improve upon taking thyroid hormone (Synthroid), at an average dosage of 100 to 120 micrograms a day.69
These two studies, plus another one showing that thyroid blood tests are only low in about 3 percent of patients whose doctors sent blood tests in, confirm what we have been saying all along.70 Our current thyroid testing will miss most patients with an underactive thyroid. Doctors of decades ago were on target when they believed that one has to treat the patient and not the blood test. Most blood tests cannot accurately measure T3 thyroid deficiency because readings measure only the level of T3 in the blood, and it’s the level inside your cells that is important. Nonetheless, it may still be worthwhile to check total or free T3 levels if you and your doctor suspect T3 deficiency. Testing should occur before beginning T3 therapy, as the tests become unreliable once you begin taking hormones that contain T3. (For a more complete discussion of the interpretation of thyroid tests, see Appendix G: For Physicians.)
From Fatigued to Fantastic! Page 12