As practitioners, we often see patients presenting with symptoms of chronic fatigue, brain fog, and stress-related dysfunction. For years, terms like “adrenal fatigue” and “cortisol steal” have been used to explain these issues. While these terms may resonate with patients and practitioners that have been practicing functional medicine for some time, they don’t hold up under scientific scrutiny.

It’s time to update our approach and focus on HPA axis dysregulation—a more accurate and evidence-based explanation of stress-related hormonal imbalances.

Adrenal Fatigue: Moving Beyond the Myth

The theory behind adrenal fatigue suggests that chronic stress causes the adrenal glands to “burn out” and stop producing adequate cortisol. But as we now understand, the adrenal glands themselves don’t actually fail.

The real issue lies in the hypothalamic-pituitary-adrenal (HPA) axis. Chronic stress alters the brain’s ability to regulate cortisol production, leading to either elevated, blunted, or dysregulated cortisol rhythms.

Patients may still exhibit symptoms like fatigue, poor recovery, and stress intolerance—but the solution is not about “recharging” the adrenals. It’s about addressing the systemic causes of HPA axis dysfunction.

The Truth About Cortisol Steal

As practitioners, you’ve likely heard the term “cortisol steal,” referring to the idea that the body redirects resources (like pregnenolone) away from sex hormone production to prioritize cortisol.

While it’s a useful metaphor, there’s no direct scientific evidence to support a “stealing” mechanism. Hormone production doesn’t work as a simple zero-sum game. Chronic stress does disrupt hormonal balance, but this is due to systemic HPA axis dysregulation, not a depletion of hormone precursors.

Do You Check Salivary Cortisol Levels?

Salivary cortisol testing is one of the most valuable tools we have for understanding the patient’s stress response. It provides insight into cortisol rhythms across the day, allowing us to identify patterns of dysregulation and guide treatment.

💡 If you’re not already using salivary cortisol testing in your practice, now is the time to start. It’s an excellent way to pinpoint where a patient’s stress response is breaking down and tailor your interventions accordingly.

Key Strategies for Addressing HPA Axis Dysregulation

In functional medicine, our role is to go beyond symptoms and address the root causes of dysfunction. Here’s how we can approach HPA axis dysregulation:

1. Salivary Cortisol Testing: Use 4-point cortisol testing to identify patterns like flattened curves or low morning cortisol, and adapt treatment plans accordingly.
2. Stress Management: Teach patients mindfulness techniques, meditation, and other stress-reducing practices.
3. Restore Circadian Rhythm: Encourage consistent sleep-wake cycles getting at least 10,000 lux of blue light for at least 30 minutes during the day and reducing blue light exposure at night.
4. Nutritional Support: Utilize key nutrients like magnesium, vitamin C, B vitamins, and adaptogens (e.g., ashwagandha, Rhodiola rosea) to support the stress response.
5. Educate Patients: Shift the narrative from “adrenal fatigue” to HPA axis dysregulation. Helping patients understand the science builds trust and empowers them to make informed choices.

Why Terminology Matters in Your Practice

Terms like “adrenal fatigue” and “cortisol steal” may have helped us connect with patients in the past, but as practitioners, we need to use language that reflects current science. Transitioning to HPA axis dysregulation not only improves our credibility but also ensures that we are offering the most effective care.

Patients trust us to guide them with evidence-based solutions. By staying ahead of the curve, we help them achieve lasting results while strengthening our practices.

Functional Medicine Practitioners: Stay Ahead

Are you ready to refine your approach to HPA axis dysfunction and other complex conditions? Join our FMP Essentials Mastermind, where you’ll gain the tools and strategies to build a thriving, evidence-based practice.

✅ Master HPA axis testing and interpretation.
✅ Learn advanced strategies to support patients with stress-related dysfunction.
✅ Collaborate with a community of forward-thinking practitioners.

🔗 Learn More and Join Here

Final Thoughts

As practitioners, we owe it to our patients to challenge outdated paradigms and embrace the latest science. The concepts of adrenal fatigue and cortisol steal may be outdated, but the symptoms they describe are very real. By focusing on HPA axis dysregulation, we can provide better care, improved outcomes, and build stronger patient relationships.

💡 Are you using salivary cortisol testing in your practice? If not, what’s holding you back? Lets discuss in our mastermind!

-Yousef Elyaman, MD, IFMCP

Founder of FMP Essentials

References:

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