The Adrenal/Thyroid Connection: A Look at the Relationship, with Drs. Richard and Karilee Shames, Authors of Thyroid Power / Thyroid Disease Information Source - Articles/FAQs
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The Adrenal/Thyroid Connection
A Look at the Relationship, with Drs. Richard and Karilee Shames, Authors of Thyroid Power

by Mary Shomon

Mary Shomon: Is there an important adrenal component to thyroid optimization?

Drs. Shames: If you have been prescribed the proper amounts of thyroid hormone -- perhaps with additional substances to balance your reproductive system -- and all is working well, you do not need attention to your adrenal glands. If, on the other hand, you are not doing as well as you'd like, and especially if your symptoms have been somewhat atypical all along, then other factors need to be considered. One of the most important additional factors to take into account is your adrenal hormone level.

Mary Shomon: What do the adrenal glands actually do?

Drs. Shames:Your adrenal glands are two tiny pyramid-shaped pieces of tissue situated right above each kidney. Their job is to produce and release, when appropriate, certain regulatory hormones and chemical messengers.

Adrenaline is manufactured in the interior of the adrenal gland, in an area called the adrenal medulla. The adrenal medulla is stimulated directly by nerves from the sympathetic portion of the autonomic nervous system, which regulates fight or flight.

The human body is organized so as to be able to respond immediately to threatening situations by generating a tremendous amount of energy in a hurry, which enables the person to run away quickly, or face the threat and fight it with a massive influx of chemical support. These chemicals increase blood pressure, heart rate, and blood flow to muscles, while mobilizing sugar to burn. Nerve impulses from the brain cause the release of adrenaline from the adrenal gland, which helps you react appropriately in immediate short-term stress situations (the "fight or flight" response).

Cortisol, the another chemical from the adrenal gland, is made in the exterior portion of the gland, called the adrenal cortex. Cortisol, commonly called hydrocortisone, is the most abundant -- and one of the most important -- of many adrenal cortex hormones. Cortisol helps you handle longer-term stress situations.

In addition to helping you handle stress, these two primary adrenal hormones, adrenaline and cortisol, along with others similarly produced, help control body fluid balance, blood pressure, blood sugar, and other central metabolic functions.

Mary Shomon: How is proper adrenal function related to a thyroid problem?

Drs. Shames: A major connection exists between low thyroid and low adrenal. Low adrenal, also called adrenal insufficiency, can actually cause someone's thyroid problem to be much worse than it would be otherwise. Correction of low adrenal is similar to correction of low thyroid. You merely take a pill that contains some of the hormone you are lacking. In the case of low thyroid, you obviously take thyroid hormone. In the case of low adrenal, you simply take some adrenal hormone. Chapter 7 in Thyroid Power assures you that doing so, when appropriate, is not only safe and effective, but it can change your life for the better.

Cortisol is in the category of medicines called steroids, a class of body substances that derive their name from the fact that they are built upon the structure of the common cholesterol molecule. Both health practitioners and the lay public have great concern about the safety of taking oral steroids. We would like to address this issue directly by making a distinction between high-dose steroid therapy and low-dose adrenal supplementation.

What we are talking about is the use of small amounts of natural adrenal hormone (hydrocortisone) to bring slightly low adrenal function up to its proper normal daily range. This is in stark contrast to the high doses of powerful synthetic adrenal hormones commonly used to treat severe health problems, or to assist in building muscles.

Mary Shomon: Why is it important for low thyroid people to know the levels of their adrenal hormones?

Drs. Shames: Adrenal insufficiency symptoms include: weakness, lack of libido, allergies, dark circles under the eyes, muscle and joint pain, dizziness, low blood pressure, low blood sugar, food and salt cravings, poor sleep, dry skin, cystic breasts, lines of dark pigment in nails, difficulty recuperating from stresses like colds or jet lag, no stamina for confrontation, tendency to startle easily, lowered immune function, anxiety, depression, and premature aging. Some of these symptoms are similar to those of low thyroid.

If low-thyroid people with these symptoms are put on thyroid hormone alone, they sometimes respond negatively. These people may have coexistent, but hidden, low adrenal. If they take thyroid hormone by itself, the resultant increased metabolism may accelerate the low adrenal problem.

The addition of thyroid hormone in this situation unmasks the also disturbing low adrenal situation. The proper approach in this case is to treat the patient with thyroid and adrenal support simultaneously.

Adrenal insufficiency, especially when unmasked by the addition of thyroid hormone, is unpleasant and uncomfortable. To compound the problem, the doctor and patient then may wrongly assume that thyroid replacement has been a mistake. A tremendous opportunity for better health has now been missed.

While uncomfortable, this dilemma can become a diagnostic tool. The doctor could then gradually add thyroid and adrenal hormone together, with the patient eventually taking optimal levels of both. This careful attention and delicate calibration are demanding on the practitioner and patient. Nevertheless, we have seen patient after patient dramatically improve with such dedication.

Also, interactions between your hormones are sometimes as important as the direct action of the hormone itself. Some adrenal hormones assist in the conversion of T-4 to T-3, and perhaps assist in the final effect of T-3 on the tissues. Some scientists believe that even the entrance of thyroid hormone into our cells is under the influence of adrenal hormones. Thus, if your adrenal level is low enough, you might do well to take both adrenal and thyroid hormone together.

Mary Shomon: I've heard that often the problem is that the adrenals are too high. Is the real problem one of excess of deficiency?

Drs. Shames: A failing adrenal gland goes through a hyper phase before it becomes totally exhausted. In the 1950;s, the famous researcher Hans Selye divided the physiology of fight or flight into three phases. In the first phase, "adaptation," a person intermittently secretes slightly higher levels of the fight or flight hormones in response to a slightly higher level of stress.

The second phase, called "alarm," begins when the stress is constant enough, or great enough, to cause sustained excessive levels of certain adrenal hormones. This can be the very earliest glimmer of what later can become stress-induced illness.

The third phase is called "exhaustion," wherein the body's ability to cope with the stress is now depleted. At this point, adrenal hormones plummet, from excessively high to excessively low. It is this latter phase of adrenal exhaustion that sometimes accompanies, or is confused with, low thyroid.

Where do low thyroid and adrenal stress intersect? If you find yourself in the alarm phase of adrenal stress (high levels of ACTH and high levels of cortisol), one result might be altered conversion of T-4 into T-3, or thyronine. Thus, your adrenal situation might profoundly affect the availability of biologically active thyroid hormone.

Research shows that even success and positive change can result in the stress response described above. In other words, even activities that you perceive as enjoyable, such as working hard on an exciting project, or striving for and receiving a promotion, can be perceived by the body as stress. This positive stress, called "eustress," can accumulate and affect bodily responses in the same way as its negative counterpart, "distress." In addition, some of the activities that are encouraged to help relieve this situation might actually make it worse, as in the following example.

Mary Shomon: How would a low thyroid person determine if he or she were low adrenal?

Drs. Shames: It would be wonderful to have a simple, reliable method of assessing a person's adrenal function. Many tests are available, but none are widely used. One reason for this is that most medical doctors consider that the adrenal system is always functioning smoothly, except in two very severe and rare circumstances. One of these is caused by extreme excess adrenal function, and it is called Cushing's Syndrome. When there is extreme decreased adrenal function, this 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.

Another reason why 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 useful except to diagnose Cushing's and Addison's, the two main types of adrenal function. 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.

Mary Shomon: What exactly are the conventional options?

Drs. Shames: 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. This involves having patients collect urine in the same large container every time they empty their bladder for an entire 24-hour period. 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 diminishing through the afternoon, reaching 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 occurred.

Also, a normal level for 24 hours might mask very high levels at one point in the day, with very low levels at another part of the day. The total for 24 hours would be normal, but the patient may go through half the day with excessively high levels, and the other half excessively low. Complicating this test is the fact that the blood cortisol level is dependent on the protein molecule that carries it around in the bloodstream. The amount of this molecule can change for a variety of reasons, which changes the level that is measured.

Complicating this test is the fact that the blood cortisol level is dependent on the protein molecule that carries it around in the bloodstream. The amount of this molecule can change for a variety of reasons, which changes the level that is measured.

Liver trouble can lower the amount of this carrier protein, which will alter your test result. Abnormal estrogen levels will also alter the amount of this protein. In addition to all this, one's level of activity can change the result of the test.

The person's 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 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. You should tell your doctor that you would like the cortisol testing, and that you want both a "free" and a "total" cortisol level. The free fraction is available in more recently-developed tests, and has more revealing information for thyroid sufferers.

Mary Shomon: Are the new alternative-medicine tests for adrenal function better than those of standard medicine?

Drs. Shames: It is true that conventional medicine's evaluation of mild adrenal insufficiency 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-hours' worth of urine, they use four separate samples collected at 8 A.M., noon, 4 P.M., 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 alarm 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 almost all the other adrenal hormones. (A precursor is a chemical that is not as far along on the chemical pathway chain as the final product.) The resulting set of numbers, which some labs call the Adrenal Stress Index or ASI, can be 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. One such saliva test is similar to the urinary ASI above. It tests four saliva samples, collected at four specific times of day (8 A.M., noon, 4 P.M., and midnight). Like the urinary tests just mentioned, more than cortisol levels are measured. Some saliva labs will check cortisol, DHEA, and pregnenolone. Pregnenalone, 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. Some alternatitve practitioners are claiming improved success with salivary testing.

Mary Shomon: In the debate about which kind of adrenal testing is best, what do you recommend?

Drs. Shames: We feel that the alternative testing of urine and saliva, evaluating four separate samples in a 24-hour period, is the preferred choice. It seems to reveal more of what is actually occurring when a patient experiences disturbingly low points in his or her day, or when proper thyroid treatment does not go well. However, these alternative tests are unlikely to reveal the true level of adrenal reserve.

Mary Shomon: How is adrenal reserve measured?

Drs. Shames: The method for measuring adrenal reserve has been largely solved by a conventional medical test, the ACTH stimulation test. Testing for adrenal reserve in this fashion is similar to the definitive thyroid test of TSH reserve (TRH Test) described in Step 4 in our book, Thyroid Power.


Richard Shames, M.D. offers consultations by telephone. To schedule an appointment, please see their website.

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