Adrenal fatigue isn’t a diagnosis, but your exhaustion still deserves one

Key takeaways

• In a Mayo Clinic lab test published in 2018, all 12 “adrenal support” supplements contained thyroid hormone and most held at least one steroid, yet no label listed a hormone¹².
• James Wilson, a chiropractor and naturopath, says he coined “adrenal fatigue” in 1998; it still has no diagnosis code, and endocrinologists say stress pushes cortisol up rather than draining it⁴⁵.
• Real adrenal insufficiency is easy to miss: in a Polish study of 60 patients, 44% were diagnosed only after a hospital stay for adrenal crisis⁶.
• Fatigue can come from anemia, sleep apnea, thyroid disease, depression and more, but testing without a clear reason may change treatment for only about 5% of patients⁸.
• Bring your symptoms and your supplement bottles to a clinician and ask for tests matched to your history, not a mail-in saliva curve¹⁵⁸.

In 2016, a team at the Mayo Clinic in Jacksonville, Florida, put 12 popular supplements to the test. All were sold online and in stores for energy, metabolism, “adrenal fatigue” or “adrenal support”¹². Six were labeled as herbal³.

The lab tested each product twice, without knowing which was which¹. Every one contained T3, an active thyroid hormone. Most held at least one steroid hormone¹. A quarter, or 3 of the 12 by our math, contained budesonide, a synthetic glucocorticoid steroid¹.

None of the labels listed a hormone².

The study, led by Halis Kaan Akturk and published in Mayo Clinic Proceedings in 2018, measured pills, not people¹². But it captures the whole adrenal fatigue story in miniature. The exhaustion is real. The explanation sold for it doesn’t hold up, and the products can carry hormones nobody meant to take.

Our article on hormone-balancing claims covers the 2016 review that found no evidence adrenal fatigue exists. This one covers where the idea came from, why it lasts, and what to check instead.

A 1998 idea gave tired people a name for what they felt

James L. Wilson, who holds chiropractic, naturopathic and PhD degrees, says on his website that he came up with it in 1998⁴. In his telling, Addison’s disease is outright gland failure, while “adrenal fatigue” is a milder, stress-driven slump in how well the glands work⁴.

Naturopaths picked up the idea, and the internet carried it much further⁴. In a feature from about 2017, Endocrine News, the Endocrine Society’s magazine, reported that functional medicine, naturopathic, chiropractic and anti-aging practitioners often made the diagnosis⁴.

A 2022 teaching presentation by Mayo Clinic physician Neena Natt summed it up: constant stress wears the adrenals down, bringing fatigue, brain fog, trouble waking up, cravings for salt or sugar and a need for caffeine³. A questionnaire or a saliva cortisol kit bought online supplies the diagnosis³. Treatment can include adrenal gland extract from animals, or even hydrocortisone, a steroid drug³.

Medicine never adopted the label. ICD-10, the coding system doctors use to record conditions, has no code for it⁵¹³. James Findling of the Medical College of Wisconsin told U.S. News & World Report that the idea has no scientific basis¹³.

The biology also points the other way. Theodore Friedman of Charles R. Drew University told Endocrine News that stress makes the adrenals put out more cortisol, not less⁴.

Still, the term answers something real. In a report in The Hospitalist, last updated in 2024, physician Pratibha Rao described patients, often young women, who had seen several doctors without getting a satisfying answer⁷.

Marcelo Campos, quoted in the same report, prefers “burnout,” which he ties to a stress response that goes off track in the brain and the HPA axis, the chain of signals running from the brain to the adrenals⁷. That puts the trouble in the signaling, not in worn-out glands, which at least fits Friedman’s point⁴⁷.

Inside the bottles: thyroid hormone, steroids and a $200 month

What the Mayo lab found across the 12 products¹:

• T3 thyroid hormone: all 12, from 63 to about 395 nanograms per tablet.
• Pregnenolone: 42%, or 5 products by our math.
• Budesonide: 25%, or 3 products.
• Androstenedione: 17%, or 2 products.
• 17-hydroxyprogesterone, cortisone and cortisol: 8% each, or 1 product apiece.

Taken as labeled, the products could deliver up to 1,322 nanograms of T3 a day, about 1.3 micrograms by our math, and up to 1,276 nanograms of budesonide¹.

Those are small amounts. Pieter Cohen of Cambridge Health Alliance and Harvard Medical School, who wasn’t involved, said in a 2018 news report that they might be too low to cause problems, though he still advised patients to avoid the products². The study didn’t test anyone’s health². The worry is what hidden hormones can do: excess thyroid hormone can harm the heart and bones, and steroid hormones can shut down a person’s own adrenal glands².

Wilson’s own four-product “Adrenal Fatigue Quartet” cost about $200 for 30 days at the lowest recommended doses at the time of the Endocrine News report⁴.

Many formulas lean on herbs. Doctors writing in the South African Medical Journal in 2018 listed ashwagandha, rhodiola, licorice root, ginseng, schisandra and maca among the plants sold to “support” the adrenals⁵. None, they wrote, had shown an objective benefit for that purpose⁵. Our ashwagandha article covers that herb’s own cortisol trials.

Some practitioners go further and prescribe a corticosteroid such as hydrocortisone³⁵. The same authors called the side effects considerable and said any risk is unacceptable when no benefit has been shown⁵.

Real adrenal failure is the diagnosis that gets missed

This is the irony. “Adrenal fatigue” is diagnosed easily, while true adrenal insufficiency, in which the glands make too little cortisol, is often caught only when it becomes an emergency.

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) says its most common symptoms are long-lasting fatigue, muscle weakness, loss of appetite, weight loss and belly pain⁹. Others include nausea, vomiting, salt craving, low mood and low blood pressure that drops further when you stand, causing dizziness or fainting⁹. In Addison’s disease, skin can darken on scars, skin folds, lips and the inside of the cheek⁹.

These symptoms build slowly and are easy to blame on something else, NIDDK warns⁹. Some people learn they have the condition only during an adrenal crisis⁹.

A 2013 study from Poland shows how often that happens. Researchers reviewed 60 patients diagnosed with primary adrenal insufficiency at one center over 12 years⁶. Every patient waited more than three months for a diagnosis, and those who arrived in crisis had waited more than six⁶. Forty-four percent were diagnosed only after a hospital stay for adrenal crisis⁶.

All 60 had lost appetite and weight⁶. The most common wrong diagnosis was ulcer disease of the stomach or upper intestine⁶.

Medicines can cause it, too. NIDDK lists suddenly stopping corticosteroid medicines after long-term use as the most common cause of one form, called tertiary adrenal insufficiency⁹. Opioid painkillers are another. In March 2016, the FDA required a new adrenal insufficiency warning on all opioid labels, calling the condition rare but serious; many reported cases came after at least a month of use¹⁴.

Ruling it out takes blood, not saliva. The South African authors call for paired early-morning levels of cortisol and ACTH, the pituitary hormone that tells the adrenals to work⁵.

Experts quoted by Endocrine News favored an ACTH stimulation test over saliva kits, plus aldosterone and renin tests for anyone with salt craving or dizziness on standing⁴. Our cortisol article explains test thresholds and the signs of crisis.

A saliva curve can’t carry the weight it’s given

Proponents of adrenal fatigue rely on several cortisol measures. They include the morning jump in cortisol after waking, a saliva cortisol rhythm sampled across the day, the total area under that daily curve, and DHEA-S, another adrenal hormone⁵. The South African authors found that these methods have produced conflicting results, and that whole-day saliva testing varies too much to be reliable⁵.

Campos made a similar point in 2024: cortisol swings so much over time that testing doesn’t work, he said⁷. The same report noted that the best sample, the best timing and even the normal ranges are still unsettled⁷.

A mail-in curve can’t tell a stressed but healthy person from someone who needs care. Our article on at-home hormone tests sorts cortisol kits by what they can answer, and our hormone-balancing article explains why saliva results can’t guide a hormone dose.

The usual suspects behind feeling tired all the time

Fatigue is one of the top reasons people see a doctor. A 2023 review in American Family Physician, the journal of the American Academy of Family Physicians, says 5% to 10% of primary care patients report it⁸. Up to 38% of U.S. workers said they’d felt fatigued in the previous two weeks⁸.

Often no single cause turns up. When young adults with new fatigue were followed in one study the review cites, about a quarter (27%) ended up with an explanation, most often anemia, low vitamin B12, an infection, pregnancy or a mental health condition⁸. A second study checked a year after the first visit: 8% of patients had a clear medical diagnosis, and nearly 17%, about 1 in 6 by our math, had a psychological one⁸.

Lab testing without a specific reason may change treatment for only about 5% of patients, or about 1 in 20⁸. That’s why the history you give matters more than the size of the lab panel.

The review’s list of causes worth weighing includes⁸:

• Sleep problems, including sleep apnea and narcolepsy.
• Blood and nutrient shortfalls, such as anemia, low iron or B12, and poor nutrition or very restrictive diets.
• Thyroid disease and diabetes, which the review checks with TSH and A1C blood tests.
• Celiac disease and infections, including COVID-19.
• Depression and anxiety.
• Medicines you take, and hard exercise without recovery.

Depression often hides behind physical complaints. The National Institute of Mental Health (NIMH) lists fatigue, low energy and feeling slowed down among its signs, and notes that many men see a doctor about physical symptoms rather than emotional ones¹¹. Thyroid problems and some medicines can mimic depression, NIMH adds, which is why an exam and lab work matter¹¹.

Some exhaustion has its own name. Myalgic encephalomyelitis/chronic fatigue syndrome, or ME/CFS, affected 1.3% of U.S. adults in 2021–2022, about 13 in every 1,000 by our math, according to the CDC’s National Center for Health Statistics¹². Women were affected more often than men, 1.7% versus 0.9%, and because the count relied on doctor diagnoses, the true number may be higher¹².

The hallmark of ME/CFS is post-exertional malaise, a crash after effort. The National Academy of Medicine’s 2015 criteria add profound new fatigue that cuts activity for six months or more, unrefreshing sleep, and either thinking problems or trouble staying upright⁸.

Long COVID can look similar, and illness that began after an infection such as mono or COVID-19 is a clue⁸. The review notes that a U.S. coalition of ME/CFS clinicians no longer recommends exercise for the condition, and it advises pacing to help prevent crashes⁸. Later articles in this series cover chronic fatigue in depth.

And if your exhaustion rises and falls with your job, burnout may be the better frame. Our burnout article covers what helps, and much of it means changing the work rather than treating your glands.

Tired all the time: the checklist

Our own guide, built from the sources cited. Use it to plan a visit, not to diagnose yourself.

If you notice…	It could point to…	Ask about…	Source
A restrictive diet, poor appetite or past anemia	Anemia or low iron, B12 or folate	Blood count, ferritin and iron, B12, folate	8
Snoring, pauses in breathing someone noticed, daytime tiredness, high blood pressure	Sleep apnea	The STOP-Bang screening questions	8
Low mood or lost interest most days for two weeks or more	Depression or anxiety	The PHQ-9 questionnaire	811
Weight change or tiredness with no clear trigger	Thyroid disease or diabetes	TSH and A1C	8
Weight loss, poor appetite, dizziness on standing, salt craving, darkening skin	Adrenal insufficiency	Morning cortisol with ACTH; an ACTH stimulation test if needed	459
Long-term opioid use, or long-term steroids stopped recently	Medicine-related adrenal insufficiency	Whether testing makes sense for you	914
A crash for days after effort, unrefreshing sleep, six months or more, often after an infection	ME/CFS or long COVID	An evaluation against the 2015 criteria, and pacing	8
A new medicine, or hard training with few rest days	A side effect or too little recovery	A medicine review and a recovery plan	8
Any “adrenal” or “glandular” supplement	Hidden thyroid or steroid hormones	Bring the bottle to your visit	12

How strong is the evidence?

Claim or approach	Rating	Why
“Adrenal fatigue” as a medical diagnosis	Evidence says no, or unsafe	No diagnosis code; stress raises cortisol rather than draining it4513
Saliva cortisol curves to diagnose it	Evidence says no, or unsafe	Conflicting results; whole-day saliva testing too variable to rely on57
Glandular or “adrenal support” supplements	Evidence says no, or unsafe	All 12 tested held thyroid hormone, most held steroids, and none listed them12
Herbs sold for adrenal support	Not enough evidence	No objective adrenal benefit shown5
Hydrocortisone or other steroids for adrenal fatigue	Evidence says no, or unsafe	Considerable side effects and no proven benefit5
Blood tests for true adrenal insufficiency	Strong evidence	Morning cortisol with ACTH, or a stimulation test, is the standard check45
Tests chosen from your history rather than broad panels	Strong evidence	Unfocused testing may change treatment for only about 5% of patients8
Prescribed exercise for ME/CFS	Evidence says no, or unsafe	No longer recommended; pacing may help prevent crashes8

Listening to your body means testing what it’s telling you

Many people drawn to the adrenal fatigue idea are doing something right: listening to their bodies, looking for a root cause and refusing to let “your labs are normal” end the conversation.

That instinct fits the evidence better than the label does. The checklist’s causes are real root causes, and several respond to things natural health already values: steady sleep, iron-rich food, rest days and care for mood. Even Endocrine News, while rejecting the diagnosis, said naturopaths’ advice has value when it centers on better diet, rest, exercise and less stress⁴.

Natt’s presentation urges doctors to listen, acknowledge the patient’s struggle and look at sleep, nutrition and mental health alongside blood tests³. Ask for that kind of visit.

When to get help

Call 911 or go to an emergency room for signs of adrenal crisis, such as severe weakness, confusion, vomiting, belly or flank pain, high fever or dizziness¹⁰.

Call or text 988 if you’re thinking about suicide, and call 911 if someone is in immediate danger¹¹.

See a clinician soon if you often feel tired or weak or are losing weight. NIDDK says catching adrenal insufficiency early can help prevent a crisis⁹. The same goes for low mood or lost interest that lasts most days for two weeks¹¹.

If a practitioner prescribed hydrocortisone or another steroid for adrenal fatigue, don’t stop it on your own. Stopping suddenly after long-term use can cause adrenal insufficiency or crisis, so plan any change with a clinician⁹¹⁰.

Questions readers ask

The bottom line

Adrenal fatigue gave many exhausted people a name for what they felt, and the exhaustion deserves to be taken seriously. But the label doesn’t match how the adrenal glands respond to stress, its saliva tests can’t separate health from illness, and products sold for it have carried hidden thyroid hormone and steroids.

The better path starts with your story. Matched to your history, a few ordinary tests and screening questions can find anemia, sleep apnea, thyroid trouble, depression, ME/CFS or true adrenal insufficiency, the condition that adrenal fatigue claims can push out of view.

Related reading

• Real hormone problems have names and tests, which “balance your hormones” claims lack
• Steroid pills can quiet your own cortisol, which is why stopping suddenly is risky
• Burnout starts on the job, and the best-tested fixes change the job
• More People Now Qualify as Low in Iron. Find the Cause Before the Pill
• Testosterone boosters promise a lift, but most ingredients were never tested for it

Sources

1. Akturk HK, Chindris AM, Hines JM, Singh RJ, Bernet VJ. “Over-the-Counter ‘Adrenal Support’ Supplements Contain Thyroid and Steroid-Based Adrenal Hormones.” Mayo Clinic Proceedings, March 2018 (abstract reproduced on Science.gov). science.gov
2. Free Malaysia Today. “Adrenal support supplements may contain unsafe ingredients.” April 26, 2018 (news report, no byline; Reuters credited for the photo).
3. Natt N. “A Systematic Approach to Medically Unexplained Symptoms” (adrenal fatigue presentation). Mayo Clinic continuing medical education, August 2022. ce.mayo.edu
4. Seaborg E. “The Myth of Adrenal Fatigue.” Endocrine News, Endocrine Society (undated online; it calls a 2016 review “last year,” so about 2017).
5. Ross IL, Jones J, Blockman M. “We are tired of ‘adrenal fatigue.'” South African Medical Journal, 2018;108(9):724–725. scielo.org.za
6. Papierska L, Rabijewski M. “Delay in Diagnosis of Adrenal Insufficiency Is a Frequent Cause of Adrenal Crisis.” International Journal of Endocrinology, 2013 (DOAJ record). pubmed.ncbi.nlm.nih.gov
7. McCall B. “Is Adrenal Fatigue a Real Condition?” The Hospitalist (MDedge), updated March 6, 2024 (trade press). blogs.the-hospitalist.org
8. Latimer KM, Gunther A, Kopec M. “Fatigue in Adults: Evaluation and Management.” American Family Physician, 2023;108(1):58–69. aafp.org
9. National Institute of Diabetes and Digestive and Kidney Diseases. “Symptoms & Causes of Adrenal Insufficiency & Addison’s Disease.” NIH, last reviewed September 2018. niddk.nih.gov
10. MedlinePlus. “Acute adrenal crisis.” Medical Encyclopedia, National Library of Medicine, reviewed April 24, 2025. medlineplus.gov
11. National Institute of Mental Health. “Depression.” NIH Publication No. 24-MH-8079, revised 2024. nimh.nih.gov
12. Vahratian A, Lin JMS, Bertolli J, Unger ER. “Myalgic Encephalomyelitis/Chronic Fatigue Syndrome in Adults: United States, 2021–2022.” NCHS Data Brief No. 488, National Center for Health Statistics, December 2023. cdc.gov
13. U.S. News & World Report. “Adrenal Fatigue: Is It Real?” Syndicated by WTOP, updated December 28, 2021 (news report).
14. U.S. Food and Drug Administration. “FDA Drug Safety Communication: FDA warns about several safety issues with opioid pain medicines; requires label changes.” March 22, 2016.