Hormonal Health
Adrenal Fatigue Protocol: A Functional Medicine Approach
How functional medicine practitioners frame "adrenal fatigue" as HPA axis dysregulation, read cortisol rhythm testing, and keep care individualized.
Functional medicine practitioners usually treat "adrenal fatigue" as HPA axis dysregulation, a disrupted cortisol rhythm tied to chronic stress, and they build care around the patient's cortisol pattern, sleep, nutrition and stressors. A 2016 systematic review found no substantiation that adrenal fatigue is an actual medical condition, so the work starts with testing the rhythm and ruling out true adrenal insufficiency, which an early-morning cortisol, corticotropin and DHEAS workup helps diagnose.
Q: What is adrenal fatigue and how does it differ from HPA axis dysfunction?
Adrenal fatigue is a popular term patients often come in with, and the same systematic review notes that no endocrinology society recognizes it. Many practitioners prefer HPA axis dysregulation as a description of a stress-related change in the daily cortisol rhythm.
Both directions are described in research. Low cortisol has been observed in stress-related disorders such as chronic fatigue syndrome, fibromyalgia and PTSD, possibly after a long period of HPA hyperactivity.
Q: What do cortisol rhythm patterns tell us?
Rhythm testing shows whether cortisol is high, low or flattened across the day compared with the lab's reference curve. The evidence is mixed, since the 2016 review found conflicting results across studies of awakening cortisol, the cortisol awakening response and salivary cortisol rhythm. Read a pattern as one input alongside the history and exam.
Q: How is care framed?
Most FM plans for HPA dysregulation center on lifestyle, with supplements in a supporting role:
- Reduce stressors: caffeine, alcohol, late-night screens, overtraining, and work or relationship strain
- Sleep: a consistent schedule and wind-down routine
- Nutrition: regular meals
- Targeted support: adaptogens or nutrients chosen by the treating clinician
The specific agents, doses and timing are individualized decisions for the treating clinician.
Q: What does the evidence say about adaptogens?
A randomized trial of a standardized ashwagandha root extract found improved stress and anxiety scores and a greater fall in morning salivary cortisol than placebo. A randomized trial of ashwagandha root extract in adults under chronic stress reported improvements in stress scores, serum cortisol and body weight. For rhodiola, a systematic review called the efficacy research contradictory, with methodological flaws in the included trials. Each agent can have contraindications and interactions that the prescribing clinician needs to review.
Q: Which tests are commonly used?
Two common options:
- DUTCH: dried urine collected at several times across the day
- Salivary cortisol rhythm: saliva samples collected at home across the day
Key Takeaways for Practice
- Rule out disease first: true adrenal insufficiency needs a standard workup
- Test the rhythm, and read it in clinical context
- Lifestyle first: stressors, sleep and nutrition
- Leave agent choice and dosing to the treating clinician
→ Pillar: Adrenal Fatigue & HPA Axis Protocol Guide
→ Hub: All research
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