Adrenal Support Protocol: A Resource for Practitioners


fullscript-leaf-greenery

by Fullscript’s Integrative Medical Advisory Team

In a 2018 survey from the American Psychological Association, it was reported that one in five adults in the United States believed they didn’t do enough to manage stress in their daily lives. The survey also found that money and work were consistently among the top stressors for adults. (3) While short-term, acute stress is both normal and necessary, unmanaged chronic stress commonly experienced by many adults can result in numerous negative health effects over time.

Chronic stress may result in dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis and subsequent imbalances in cortisol, the body’s primary stress hormone produced by the adrenal glands. (10) Certain dietary supplements known as adaptogens may help support HPA axis function and modulate cortisol levels during times of physical or psychological stress. (17) This article will review the body’s physiological response to stress, outline the signs and symptoms of cortisol dysregulation, and provide an integrative protocol for adrenal support.

Father working on a computer with son

Certain dietary supplements can be used to support your mental and physical health under stress.

The role of adrenal glands in stress

A stressor is defined as a real (physical) or perceived (psychological/social) threat to an individual’s safety. Examples of stressors include physical pain or injury, work overload, social embarrassment, and financial stress. (10) When an individual perceives a threat, a physiologic stress response occurs in the body.

In cases of acute stress, the amygdala, found in the brain’s limbic system, will trigger the first phase of the stress response in the sympathetic nervous system, known as the body’s fight-or-flight reaction. This response is followed by a response in the neuroendocrine system. The first phase involves the release of catecholamines into the bloodstream, which produces a number of effects, such as increased blood pressure, heart rate, respiration, and inflammation. (10)

The second phase of the stress response activates the hypothalamic-pituitary-adrenal (HPA) axis, which initiates a hormonal cascade that stimulates the release of cortisol from the cortex of the adrenal glands. Cortisol decreases inflammation, mobilizes glucose (sugar) for use as energy, and suppresses non-vital organs. (10) All of these effects assist the body in coping with the stressor and returning to homeostasis, a state of physiological balance in the body.

Chronic stress and adrenal function

While the stress response is healthy and necessary to overcome an acute stressor or threat, research shows that chronic exposure to stress may result in excessive cortisol secretion by the adrenal glands over a long period of time. (10)

Signs and symptoms of high cortisol include:

  • Insulin resistance
  • Acne and hirsutism in females
  • Central obesity (2)
  • Reduced immune function and prolonged recovery time
  • Delayed growth in children
  • Increased blood pressure
  • Increased heart rate (1)

Patients with elevated cortisol have a higher risk of developing osteopenia, osteoporosis, and diabetes mellitus. (2)

Continued exposure to stress and overstimulation of cortisol secretion will eventually result in cortisol dysfunction, which may present in a number of ways, including impaired cortisol secretion, insufficient free (unbound) cortisol, or glucocorticoid receptor (GCR) resistance, which results in a decrease in the sensitivity of target tissues to cortisol’s effects. (10)

Signs and symptoms of low cortisol or GCR resistance include:

  • Pain (e.g., musculoskeletal) (9)(13)
  • Fatigue
  • Enhanced stress sensitivity (9)
  • Depression (11)
  • Gastrointestinal effects
  • Headaches
  • Dizziness (13)

Hypocorticolism (low cortisol) induced by chronic stress has also been associated with certain pain somatization disorders, including:

  • Fibromyalgia (FM)
  • Chronic fatigue syndrome (CFS)
  • Chronic pelvic pain
  • Temporomandibular disorder (10)
Woman sitting on sofa in a doctor’s office.

Adaptogenic herbs may help to support the HPA axis and balance cortisol levels.

Integrative protocol for adrenal support

When indicated, adaptogens, a type of herbal dietary supplements, can be used to improve resistance to stress and balance cortisol levels. Adaptogens, such as ashwagandha, Rhodiola rosea, and Panax ginseng, have been shown to play a role in the regulation of the HPA axis, as well as improve mental work capacity and tolerance to mental fatigue during periods of stress. (17)

It’s important to note that certain disease states related to adrenal gland dysfunction, which are beyond the scope of this protocol, may result from reasons beyond chronic stress. These conditions include Cushing’s syndrome (excessive production of adrenocorticotropic hormone), pituitary tumors, Addison disease (adrenal insufficiency), and hyperaldosteronism (excessive production of aldosterone). (15)

Ashwagandha (Withania somnifera)

Ashwagandha, also known as ”Indian ginseng” or “winter cherry”, is a commonly used herb in Ayurvedic medicine. The root of the ashwagandha plant contains bioactive constituents known as withanolides. (6) Research suggests that ashwagandha is a safe and effective therapy when used to improve stress resistance in humans. (4) Ashwagandha has also been shown to possess antioxidant, immunomodulating, neuroprotective, antifungal, anti-inflammatory, and cardioprotective effects. (5) Specific to stress management, ashwagandha has clinical applications for patients with stress-related nervous exhaustion, insomnia, and debility. (6)

Research findings:

  • Serum cortisol, body weight, and body mass index, Perceived Stress Scale and Food Cravings Questionnaire, Oxford Happiness Questionnaire and Three-Factor Eating Questionnaire were all improved (4)(5)
  • Ashwagandha safely improved resistance to stress in individuals (4)

For a more detailed review of Withania somnifera, refer to the Fullscript reference sheet!

CAN: Search for Withania Somnifera in the Fullscript catalog.
US: Search for Withania Somnifera in the Fullscript catalog.

dried rhodiola herb on a canvas background with flowers

Rhodiola is known for its beneficial impact on both physical and mental fatigue.

Rhodiola (Rhodiola rosea)

Rhodiola is a biennial plant that grows in high latitude and altitude regions, such as Europe, Asia, and Russia. (12) The roots and rhizome of the plant contain approximately 140 various active compounds, such as monoterpene alcohols and their glycosides, flavonoids, flavonolignans, proanthocyanidins, and gallic acid derivatives. (18) Much of the research on this herb has focused on its benefits for stress-related mental and physical fatigue. (12)

Research findings:

  • Rhodiola increases mental performance including the capacity to concentrate and decreased cortisol response to awakening stress (16)
  • Improvement in general fatigue including aspects like physical and mental fatigue, neuro-motoric tests and overall wellbeing was shown to be significantly improved (7)(19)

For a more detailed review of Rhodiola rosea, refer to the Fullscript reference sheet!

CAN: Search for Rhodiola rosea in the Fullscript catalog.
US: Search for Rhodiola rosea in the Fullscript catalog.

Panax ginseng

Panax ginseng, also known as Asian or Korean ginseng, is an adaptogenic herb that has a long history of use in Asia. Ginsenosides, a group of steroid-like saponins, have been identified as the primary active components of the herb. Panax ginseng exerts many therapeutic actions, such as neuroprotective, antioxidant, anti-inflammatory, antiapoptotic, immunostimulant, and anticancer effects. (20) Panax ginseng can be used clinically to address symptoms of fatigue and reduce HPA responses to physical stress. (8)(14)

Research findings:

  • Numerical rating scale (NRS) score, a self-assessment of fatigue severity, was improved (14)
  • Has been shown to reduce circulating cortisol while increasing enzymatic and nonspecific antioxidant activity in response to physical stress (8)
  • Dosing of 2000 mg per day improved the visual analogue scale (VAS) results
  • Reactive oxygen species (ROS) and malondialdehyde (MDA) levels were lowered and dosing of 1000 mg increased GSH concentration and activity (14)

CAN: Search for Panax Ginseng in the Fullscript catalog.
US: Search for Panax Ginseng in the Fullscript catalog.

The bottom line

Adaptogens such as ashwagandha, Rhodiola rosea, and Panax ginseng have been shown to help the body adjust to stress, balance cortisol levels, and support the function of the HPA axis. A protocol using natural supplements can be used therapeutically on its own or as an adjunct to existing treatment. If you are not an integrative healthcare provider, we recommend speaking with one to find out whether these supplements are right for your wellness plan.

If you are a practitioner, consider signing up to Fullscript. If you are a patient, talk to your healthcare practitioner about Fullscript!

To see our full protocol library, click here!


Disclaimer

The Fullscript Integrative Medical Advisory team has developed or collected these protocols from practitioners and supplier partners to help health care practitioners make decisions when building treatment plans. By adding this protocol to your Fullscript template library, you understand and accept that the recommendations in the protocol are for initial guidance and may not be appropriate for every patient.

  1. Aguilar Cordero, M. J., Sánchez López, A. M., Mur Villar, N., García García, I., Rodríguez López, M. A., Ortegón Piñero, A., & Cortés Castell, E. (2014). [Salivary cortisol as an indicator of physological stress in children and adults; a systematic review]. Nutricion Hospitalaria, 29(5), 960-8.
  2. Allen, M. J., & Sharma, S. (2019). Physiology, adrenocorticotropic hormone (ACTH). In StatPearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK500031/
  3. American Psychological Association. (2018). Stress in America: Generation Z. Retrieved from https://www.apa.org/news/press/releases/stress/2018/stress-gen-z.pdf
  4. Chandrasekhar, K., Kapoor, J., & Anishetty, S. (2012). A prospective, randomized double-blind, placebo-controlled study of safety and efficacy of a high-concentration full-spectrum extract of ashwagandha root in reducing stress and anxiety in adults. Indian journal of psychological medicine, 34(3), 255-262.
  5. Choudhary, D., Bhattacharyya, S., & Joshi, K. (2017). Body weight management in adults under chronic stress through treatment with ashwagandha root extract: A double-blind, randomized, placebo-controlled trial. Journal of evidence-based complementary & alternative medicine, 22(1), 96-106.
  6. Cooley, K., Szczurko, O., Perri, D., Mills, E. J., Bernhardt, B., Zhou, Q., & Seely, D. (2009). Naturopathic care for anxiety: a randomized controlled trial. PloS one, 4(8), e6628.
  7. Darbinyan, V., Kteyan, A., Panossian, A., Gabrielian, E., Wikman, G., & Wagner, H. (2000). Rhodiola rosea in stress induced fatigue: A double blind cross-over study of a standardized extract SHR-5 with a repeated low-dose regimen on the mental performance of healthy physicians during night duty. Phytomedicine, 7(5), 365-371.
  8. Flanagan, S. D., Dupont, W. H., Caldwell, L. K., Hardesty, V. H., Barnhart, E. C., Beeler, M. K., . . . Kraemer, W. J. (2018). The effects of a Korean ginseng, GINST15, on hypo-pituitary-adrenal and oxidative activity induced by intense work stress. Journal of Medicinal Food, 21(1), 104-112.
  9. Fries, E., Hesse, J., Hellhammer, J., & Hellhammer, D. H. (2005). A new view on hypocortisolism. Psychoneuroendocrinology, 30(10), 1010-1016.
  10. Hannibal, K. E., & Bishop, M. D. (2014). Chronic stress, cortisol dysfunction, and pain: a psychoneuroendocrine rationale for stress management in pain rehabilitation. Physical therapy, 94(12), 1816-1825.
  11. Hellhammer, J., Schlotz, W., Stone, A. A., Pirke, K. M., & Hellhammer, D. (2004). Allostatic load, perceived stress, and health: A prospective study in two age groups. Annals of the New York Academy of Sciences, 1032(1), 8-13.
  12. Ishaque, S., Shamseer, L., Bukutu, C., & Vohra, S. (2012). Rhodiola rosea for physical and mental fatigue: A systematic review. BMC complementary and alternative medicine, 12, 70.
  13. Janssens, K. A., Oldehinkel, A. J., Verhulst, F. C., Hunfeld, J. A., Ormel, J., & Rosmalen, J. G. (2012). Symptom-specific associations between low cortisol responses and functional somatic symptoms: The TRAILS study. Psychoneuroendocrinology, 37(3), 332-340.
  14. Kim, H. G., Cho, J. H., Yoo, S. R., Lee, J. S., Han, J. M., Lee, N. H., … Son, C. G. (2013). Antifatigue effects of Panax ginseng C.A. Meyer: A randomised, double-blind, placebo-controlled trial. PloS one, 8(4), e61271.
  15. National Institutes of Health. (2017). What are the symptoms of adrenal gland disorders? Retrieved from https://www.nichd.nih.gov/health/topics/adrenalgland/conditioninfo/symptoms
  16. Olsson, E., Schéele, B. V., & Panossian, A. (2009). A randomised, double-blind, placebo controlled, parallel group study of the standardised extract SHR-5 of the roots of Rhodiola rosea in the treatment of subjects with stress-related fatigue. Planta Medica, 75(09).
  17. Panossian, A., & Wikman, G. (2010). Effects of adaptogens on the central nervous system and the molecular mechanisms associated with their stress-protective activity. Pharmaceuticals, 3(1), 188-224.
  18. Panossian, A., Wikman, G., & Sarris, J. (2010). Rosenroot (Rhodiola rosea): Traditional use, chemical composition, pharmacology and clinical efficacy. Phytomedicine, 17(7), 481-493.
  19. Spasov, A. A., Wikman, G. K., Mandrikov, V.B., Mironova, I. A., & Neumoin, V. V. (2000). A double-blind, placebo-controlled pilot study of the stimulating and adaptogenic effect of Rhodiola rosea SHR-5 extract on the fatigue of students caused by stress during an examination period with a repeated low-dose regimen. Phytomedicine, 7(2), 85-9.
  20. Xiang, Y., Shang, H., Gao, X., & Zhang, B. (2008). A comparison of the ancient use of ginseng in traditional Chinese medicine with modern pharmacological experiments and clinical trials. Phytotherapy Research, 22(7), 851-858.