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From the Townsend Letter
January 2018

Cortisol Deficiency: Frequent, Life-Impairing, and How to Give Patients Their Lives Back by Correcting It  Part 1
by Thierry Hertoghe, MD
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Thirdly, cortisol increases the supply of blood, oxygen, and nutrients to the brain, muscles, and inner organs by raising the blood pressure53 through an increase in salt and water retention in the kidneys and vasoconstriction and through the stimulation of contractions of the thick smooth muscle layers that wrap up the arteries. Fourthly, cortisol "burns" fat.54-55 This lipolysis liberates energy.
A second important action of glucocorticoids is to reduce inflammation. Cortisol considerably reduces the migration of leukocytes into inflammatory zones.56-57 The accumulation of these white blood cells at the sites of inflammation causes swelling, compression, and pain. Cortisol also blocks collagen overproduction,57 which makes inflamed tissues thick and hard. Collagen is the main protein that fills up the spaces between cells in the tissues. By reducing collagen formation during inflammation, cortisol prevents fibrosis and, thus, formation of excessively thick scars or keloids and scleroderma, which is the disease that affects the skin and organs with fibrosis.
Klaire LabsAt high doses, cortisol's anti-inflammatory effect may atrophy the major immune gland, the thymus. However, thymus atrophy and immune depression only appear when cortisol treatment is imbalanced (i.e., too much cortisol without sufficient addition and protection by anabolic hormones and protein-rich foods). High doses of glucocorticoids without DHEA protection also produce skin, muscle, and bone atrophy, which are other well-known side effects of cortisol overdoses.
It is always the same story: too much of a good thing is too much. To use cortisol safely, it is important to administer physiological doses. In cases of higher needs, to the doses of cortisol can be temporarily increased if supplementary doses of anabolic hormones, such as DHEA, are also added.

By reducing inflammation, cortisol may also block the appearance of allergies. The increasingly higher frequency of allergies in people is partially due to pollution and intestinal problems – the known triggers of allergies – but is almost always a sign of adrenal deficiency. The adrenals glands do not secrete sufficient amounts of cortisol, which is the anti-allergy hormone. The loss of cortisol's anti-inflammatory action also explains why cortisol-deficient patients typically suffer from intolerance to all kinds of medications.

Cortisol also provides beneficial effects through its insufficiently known antioxidant activity. Cortisol neutralizes free radicals preventing free radical tissue damage,58-60 a property especially useful in stressful conditions, which are associated with an increase in free radical production. Free radicals originate from oxygen molecules through the loss of an electron and become, for this reason, tissue-damaging compounds. The more free radicals are formed, the greater "oxidative stress" is inflicted on the body, thus damaging tissues, and the more tissues prematurely age.
Last, but not least, and contrary to belief, cortisol does not increase fat but breaks down fat.54-55 Weight gain that tends to appear with high-dosed cortisol supplements is not due to a direct stimulation of fat production by cortisol but through a stimulation of the appetite and an increased intake of weight-increasing foods, such as sugar and grains (bread, porridge, muesli, pasta, etc.).

Types of Cortisol Deficiency
There are three types of cortisol deficiency depending on the tissue that causes the deficiency. In primary cortisol deficiency, also called Addison's disease (following the name of Dr. Addison, who was the first to describe the disease), the adrenal glands themselves are weak and unable to secrete a sufficient amount of cortisol. President Kennedy suffered from Addison's disease and took a treatment for it.61 In secondary cortisol deficiency, the production by the pituitary gland of ACTH, the hormone that stimulates the adrenals to produce cortisol, is deficient. In tertiary cortisol deficiency, the production by the hypothalamus of CRH (corticotropin releasing hormone) that stimulates the secretion of ACTH is failing.

Diagnosis of Cortisol Deficiency
The diagnosis of cortisol deficiency is based on clinical and laboratory assessments confirmed by a successful therapeutic trial. To diagnose cortisol deficiency, laboratory tests (blood and urinary), an evaluation of all complaints, and physical signs of cortisol deficiency are needed. When sufficient findings suggest a cortisol deficiency, a glucocorticoid treatment trial should be engaged to confirm the deficiency. If the patient feels better, looks much better, and laboratory tests show no excess with the glucocorticoid therapy, then the diagnosis of cortisol deficiency is confirmed, and cortisol treatment should be continued. If the glucocorticoid treatment does not give any result, doses may be too low and a trial at higher doses should be undertaken. If the treatment provides overdose symptoms, even at low doses, then the treatment is contraindicated.

Psychological Complaints of Cortisol Deficiency
Individuals with cortisol deficiency are tired62-66 as soon as they have to exert effort or fall into stressful situations. People with adrenal deficiency lack the punch to react efficiently to stressful events. If they react, they quickly feel tired, even exhausted, and cannot face any new strains. If demands are high at their work, they end up being burned out, which is almost literally an "adrenal burnout" or a severe depletion of the adrenals stocks of cortisol-making patients no longer able to face normal daily life difficulties. Cortisol deficiency is the main deficiency behind the feelings of burnout.
The fatigue in cortisol deficiency has in my experience several characteristics. It consists of a lack of energy, flu-like feelings, a lower capacity to react well to stress, and a foggy feeling in the head. The lack of energy of cortisol deficiency62-65 predominantly results from hypoglycemia - the lack of sugar. In stressful conditions, it exponentially worsens. The flu-like character of fatigue,67-68 where every part of the body feels uncomfortable, is due to the generalized inflammation of cortisol deficiency. The lack of punch to react to stress, typical of patients with cortisol deficiency, is due to low glycogen stores and low dopamine receptor numbers. The glucose stocks and dopamine activity are insufficient to increase the energy levels and cope with new stressful situations. Insevere cortisol deficiency, the lack of energy to react to events can become an inability to react, literally paralyzing the patient in stressful conditions where more energy is required. Coping with new stressors then becomes difficult or even impossible.
The fogginess and empty headedness of cortisol-deficient patients is due to a low blood pressure69 that substantially reduces the blood supply to the highest parts of the body when standing, particularly the brain.
In the early stages of cortisol deficiency, patients may react very emotionally to events in an outburst of anger or anxiety, compensating for the lack of cortisol by peaks of adrenaline and noradrenaline. In later stages of increasingly greater adrenal deficiency, the adrenal medulla that secretes the catecholamines also wears out, leaving the patient without reaction to a new stressor. This severe situation is typical of burnout.
Cortisol-deficient patients are excessively sensitive to stress.70-73 They feel the world is stressful and difficult to live in because it is full of worries and aggressiveness. Cortisol-deficient patients tend to find that others, especially people close to them, family members, and colleagues at work, put excessive pressure on them.
Because of this feeling of excessive pressure, cortisol-deficient patients tend to be nervous and irritated. Irritability is the most typical psychological symptom of cortisol deficiency74-76 due to increased secretions of adrenaline and noradrenaline. These neurotransmitters make individuals nervous and are secreted in higher amounts to compensate for the low cortisol. Outpourings of adrenaline and noradrenaline not only cause nervous behavior but also anger and anxiety outbursts.
In cortisol deficiency, the brain and nerves easily inflame. Brain inflammation makes patients feel that life is "inflamed," more stressful, and even dramatic. This dramatization of problems and life events, which seems minor and easy to treat for healthy individuals, may appear to be extremely important and difficult to cortisol-deficient patients and make them use harsh, sharp words that reveal their inflamed perception of the world, such as "terrible," "horrible," "miserable," "a catastrophe," a disaster," and "you are killing me."

The Paranoid Behavior of Cortisol-Deficient Patients
Patients with cortisol deficiency suffer more than the average population would in similar stressful conditions. Because their suffering feels unbearable, they seek causes to their pain, hoping that they may find solutions by finding causes outside themselves. As it is easier to find a cause outside than inside of oneself, they tend to suspect others of being the cause of their suffering, often their closest relatives, such as the partner, family members, friends, or colleagues at work. In cortisol-deficient patients, a suspicion quickly becomes a conviction and transforms into accusations. They accuse others of being the cause of their suffering and tend to persecute them, surprising them by their overreactions.
The recurrent accusatory behavior explains the paranoid tendencies of cortisol-deficient patients and is the basis of the paranoid character typical to cortisol deficiency.76-79 One of cortisol's roles is to reduce the production and levels of adrenaline and noradrenaline  –  neurotransmitters that make us overreact in a crazy, violent way and giving us the sudden desire to harm a person or oneself, sometimes even to murder or suicide!
The accusations form the base of the quarrelsomeness, which is another typical symptom of cortisol-deficiency. Patients tend to quickly interpret others' offhand words as negative criticisms. In reaction, they utter sudden and violent accusations. In turn, these nervous reactions trigger heavy protest from the accused person in self-defense, and quarrels start over again. This quarrelsomeness induced by minor stresses makes life difficult for family members or colleagues at work.

Cortisol Deficiency and Stress
Cortisol deficiency complaints increase in intensity during stressful conditions. In calm, relaxing situations, patients with cortisol deficiency do not suffer much, if any, from their disorder. In stressful conditions, however, cortisol deficiency complaints come up and increase almost exponentially in intensity because these patients cannot make the supplementary amounts of cortisol necessary to cope with stress. Their adrenals barely make enough cortisol for the needs of an easy sedentary life where rest is central, and work or performance is secondary.
Healthy adrenal glands produce supplementary amounts of cortisol whenever supplementary work has to be done or whenever a dangerous situation occurs (i.e., to respond to the difficult situation, fight back, or run away from it). The energy comes from a higher sugar level, blood pressure, and number of dopamine receptors.
Inevitably, due to their negative life experiences, patients with cortisol deficiency tend to express negative thinking and have a low mood.80 Table 1 shows the most typical psychological complaints of cortisol deficiency.

Table 1. Psychological Complaints of Cortisol Deficiency
(Particularly frequent and intense in stressful conditions)

  • Flu-like fatigue
  • Outbursts of nervousness, anger, fear
  • Lack of punch
  • Use of intensely negative words: horrible, terrible, dramatic, disaster, the end of the world, etc.
  • Poor resistance to stress
  • Intense dislike of stress
  • Irritability, aggressiveness, even meanness
  • Try to avoid stressful situations, jobs, partner
  • Quarrelsomeness
  • Accusations, meanness toward others

Physical Complaints of Cortisol Deficiency
In adrenal deficiency, the body feels tense, particularly the muscles, due to high catecholamine levels, producing tachycardia and (heart) palpitations in stressful conditions. Wet armpits, wet hand palms, and wet foot soles occur in stressful conditions due to excessive sweating, also resulting from high adrenaline and noradrenaline secretions. The body tries to compensate for the lack of cortisol by increasing the secretion of catecholamines.
Other complaints are due to inflammation. Cortisol-deficient patients easily complain that the body hurts all over,81 including abdominal (digestive),82-83 muscle,84-85 and joint pain,85-89 and even the hair and skin may feel unpleasant to the simple touch due to compression of the nerves by inflammation. Table 2 shows the physical complaints of cortisol deficiency. The same type of pain sensation is also seen during the flu. Patients with cortisol deficiency have a weak immune system that makes them prone to infections. They can get one infection after the other.
The flu puts people in a state of cortisol deficiency.67-68 The influenza virus blocks the secretion of ACTH, which is the pituitary gland hormone that stimulates the adrenal glands to make cortisol. The lack of ACTH causes the cortisol production to drop, and the flu-like symptoms of cortisol deficiency to appear.90
A generalized lack of energy caused by low sugar levels is a predominant sign of the flu and of cortisol deficiency. A desire to lie down, caused by low blood pressure, pain aches in the whole body, and sore throat and red eyes initiated by inflammation are other dominant signs of the flu due to cortisol deficiency.

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