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HPA Axis Dysfunction vs Adrenal Fatigue

Fatigue is perhaps one of the most common health complaints that people have when going to their doctor. 

The term “adrenal fatigue” has become commonplace as a condition that explains why so many are tired.  Despite its popularity, the idea that the adrenal glands become ‘fatigued’ just isn’t backed up by the ever-changing body of medical research.

It’s commonly argued that the symptoms of fatigue, poor sleep, anxiety, weight gain and all others that fit within the constellation of symptoms commonly ascribed to adrenal fatigue, are due to low cortisol levels.

The concept behind adrenal fatigue is that as stress increases, so do cortisol levels to the point that the adrenal glands become ‘fatigued’ and can no longer produce cortisol in adequate amounts.

Hypothalamic-Pituitary-Adrenal Axis Dysfunction

However, there is a problem with this idea and that is the majority of people with “adrenal fatigue” don’t actually have low cortisol levels. Saliva levels can be low, however they don’t actually reflect a system-wide shortage. In fact, total cortisol production is often normal or even high in those with adrenal fatigue.

Instead, the symptoms that many ascribe to adrenal fatigue are more properly attributed to a condition known as hypothalamic-pituitary-adrenal axis dysfunction, or HPA-D

Here’s what we do know:  The stress response is governed by a system known as the hypothalamic-pituitary-adrenal (HPA) axis.  The hypothalamus is the part of our brain that interprets stress in the environment, and then signals the pituitary gland (located in the brain) to release the ‘master hormones’ which then influence our endocrine organs - adrenals, thyroid, ovaries, testicles, breasts and other body tissues.

When we become stressed, the hypothalamus signals the pituitary gland to in turn release different neurochemicals that in the end lead to the release of hormones and neurotransmitters like cortisol, epinephrine and norepinephrine.  These chemicals in turn directly influence the function of tissues throughout the body.

After time, the ongoing stimulation of our stress response system starts to chew away at our reserves - mental, emotional and physical. As our resilience to stressors erodes, the body fights to adapt and maintain our normal physiological balance.

This is where we see actual changes in cortisol levels - usually we make too much, or the normal diurnal (daily) rhythm becomes imbalanced. This is where we might see too little cortisol in the morning, or too much at night.

And, nothing in the body happens alone. If one hormone system is imbalanced, then others are as well.  In chronic stress states we also see altered production of neurotransmitters (brain chemicals) and hormones like DHEA, melatonin, progesterone, estrogen and testosterone.

Clearly, this isn’t a problem limited to weak adrenal glands. ALL stressors (emotional, mental, physical, environmental, dietary, etc) impact the HPA axis and when disrupted, the effects are felt in almost every organ system of the body - this is why the symptoms are so diverse and often confounding to physicians not trained in a naturopathic approach to health and medicine.

Common Signs & Symptoms of HPA Axis Dysfunction:

  • Weight gain, especially around the waist and stomach

  • Exhausted despite plenty of sleep

  • Frequent awakening at night; poor sleep

  • Waking tied, despite sleeping all night

  • Inability to recover from exercise

  • Frequent illness, especially respiratory infections

  • Inability to cope with stress; completely ‘wiped out’ after a stressful situation

  • Foggy brain

  • Dizziness when standing up

  • “Tired, but wired” in the late evenings (sleepy but can’t fall asleep)

  • Craving caffeine or sugar to get moving in the morning

Diagnosing HPA Axis Dysfunction

herbs for HPA dysfunction

Making a true diagnosis is challenging.  Traditional medicine will more than likely not acknowledge this condition (only because training in this area is rare); naturopathic or functional clinicians can help guide the way however it’s not always a slam dunk diagnosis.  HPA Axis dysfunction (HPA-D is a functional diagnosis, meaning there isn’t one single test or set of tests that defines it.

Testing adrenal hormones (cortisol & DHEA), estrogen and progesterone (in women) and testosterone in men is a good place to start. You can test these hormones yourself at home using a  convenient at home saliva test. Blood testing doesn’t offer the sensitivity that a saliva test does when looking for HPA-D.

Testing cortisol throughout the day (upon awakening, noon, early evening and bedtime) helps to estimate if there is true imbalance in the adrenal hormone system; measuring estrogen, progesterone and testosterone can also provide insight into any imbalance.

Treating HPA-Dysfunction

Treatment can be complicated and will differ from person to person in many cases. However, addressing both lifestyle and supplemental support are foundational first steps.


  • Stress management 
    Mental-emotional stress taxes the HPA axis perhaps even more than physical stress does. Managing stress - whichever way works for you - is imperative to lower the stress response.

  • Diet 
    Sugars and foods that are rapidly metabolized into sugar can be a source of ongoing stress to the body as it works to stabilize blood sugar levels in the bloodstream. Every meal should be rich in fiber, protein and fat instead of sugars and simple carbs. 

  • Rest 
    Exercise should be minimal and only slightly stimulating. Think recovery-zone workouts. Keeping workouts at low intensity minimizes physical stress.


In addition to stress management, supplementation can offer a supportive role as the body regains balance.

  • Adrenal B Complex: B complex + adaptogenic botanical medicines help support the body’s stress response.

  • Vitamin C: Acts as an important anti-oxidative to combat the pro-oxidative effects of chronic stress throughout the body.

  • Rhodiola: One of the first prominent adaptogenic botanicals, it has good clinical research showing benefit under ongoing stressful conditions.

  • DHEA:  Dehydroepiandrosterone is one of the hormones affected by HPA-D; supplementation at low doses can help support levels in the body.

  • Cortisol Recovery: Oftentimes cortisol levels become elevated in the evening in states of HPA-D.  Elevated nighttime cortisol can lead to insomnia, elevated blood pressure, increased appetite, weight gain and anxiety.  Cortisol Manager helps to minimize elevated levels of cortisol in the evenings.

Recovery from HPA-D takes time and adherence to a support regiment, and perhaps most importantly taking steps to minimize stress as much as possible. As long as the body is in a high-stress state, it will be difficult to bring balance to the HPA axis.

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