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Testing Adrenal Fatigue with the Adrenal Stress Index




by Marek Doyle of

Marek is a nutritional therapist, allergist and personal trainer operating in London and Basingstoke, UK.


As the number of people that suffer with adrenal fatigue continues to rise, so to does the number of people undertaking tests to establish adrenal function. The most popular of these is the Adrenal Stresas Index (ASI).



The ASI is a four-point test offered by a number of laboratories that measures the saliva for levels of cortisol and DHEA. Typically, these are 2ml samples glamourously dribbled into the provided containers, and are collected at 8am, 12noon, 4pm and 8pm. By analysing the concentrations of these two steroid hormones, practitioners are able to identify adrenal fatigue and create an appropriate treatment plan.

As a practioner known for dealing with adrenal fatigue and it related complications, I see a wide range of clients, many noticing the same patterns but each with their own experiences of adrenal fatigue and individual set of symptoms. I always order an Adrenal Stress Index in every case. All tests have their limitations, but this test is vital to establish how best to re-establish normal adrenal function for the client; adrenal dysfunction affects everything from blood sugar levels and the immune system to sex drive and memory. In many cases, a deficiency of DHEA can mimic a shortfall in cortisol, so assessment is vital.

By the time a client contacts me, they are normally in Stage 3 Adrenal Fatigue. This is the stage where the tissues within the adrenal cortex that manufacture the hormones have been overworked for so long that they fail, producing acute insufficiency. This is the basis for the huge range of symptoms experienced. In these cases, I normally see low cortisol for the first three collections and then normal/high cortisol at 8pm. On a graph, this often resembles a straight line instead of the the healthy pattern, which sees cortisol peak on the first collection and steadily fall throughour the day. The 'straight line' is a classic pattern, whereby the tissues producing cortisol cannot keep pace with the demand (the brain signals to the adrenals to produce cortisol through the release of the pituitary hormone ACTH). Regardless of how much the adrenals are activated by ACTH, they cannot produce enough cortisol for the task in hand; output remains low all day. Meanwhile, output of DHEA is often higher than normal (due to ACTH stimulation) or within reference range.

Only when the demand finally falls (towards the end of the day) does cortisol output begin to keep pace; the only problem is that these tissues have been receiving ACTH signals for so long that they keep pumping out cortsiol longer than necessary, keeping the individual awake well into the night. This is why many sufferers of adrenal fatigue feel like 'death warmed up' in the morning but begin to feel productive late at night. Without intervention, these cases are unlikely to show any improvement as, due to the low serum cortisol, the body releases a stream of ACTH which constantly bombards the tired adrenals with more 'requests' to produce more cortisol. These tissues are already burnt out, and this set-up ensures that this remains the case. Treatment will consist of the breaking this cycle; together with the normal lifestyle/dietary changes,  cortisol replacement of 5-15mg/day or use of licorice root, for around 8 weeks, is enough to return systemic cortisol levels to where they should be, reduce the stream of ACTH that is bombarding the adrenals, and provide them with some respite, during which healing may occur.

It is important to stress that, even if your energy levels match this pattern, the appropriate treatment for you may be totally different to that mentioned. Although it is witnessed less regularly, the tissues responsible for DHEA production can crash in precisely the same way. DHEA and cortisol are opposed in many of their actions, yet insufficient DHEA can produce the same wide variety of symptoms – sugar cravings, low blood pressure, depression, 'tired but wired' feeling, constant infections, weight gain – as insufficient cortisol. DHEA replacement at 10-40mg/day for 8 weeks has been a reliable way to re-establish a healthy balance and to allow the tissues responsible for DHEA production to heal. Like all steroid hormones, DHEA should not be taken without the supervision of a suitably-experienced practitioner. As a precursor to estrogen and testosterone, DHEA supplementation can have a number of unexpected effects; this is especially true in women, as those suffering from adrenal fatigue are almost certainly not ovulating, which means they will not be producing sufficient progesterone to balance the higher levels of estrogen that their body is now likely to produce following the introduction of DHEA.

If your results show you that both DHEA and cortisol are low, then it may be worthwhile testing ACTH output, as this hormone stimulates release of both substances. In most cases, though, this situation exists simply as a simultaneous crash that occurs in the tissues of both DHEA-producing adrenal tissue and that which produces cortisol. There is no set order of failure when the adrenals are overloaded over a significant period of time, just in the same way that some people can sustain excessive stress loads for many years before finally succumbing to a crash, whereas others will reach their limit in just a few months. The cause may be the same and the symptoms similar, but the biochemistry of two patients is rarely identifical and thus the treatment slightly different.

These three examples, whilst the most popular patterns seen from an Adrenal Stress Index, are not the only patterns seen from these tests. Taking measurements of two hormones at four points in the day can show a surprisingly wide range of different patterns. It is important to remember that these tests do not measure the behaviour of the adrenal medulla (which releases adrenaline), which is also affected in all cases of adrenal fatigue, and that complex interactions of sex hormones, thyroid hormones and liver function will result in different clients noticing different issues. Adrenal fatigue is a condition that affects the whole body and must be treated holistically.

The main uses of an Adrenal Stress Index are to act as a confirmation of diagnosis (admistering hormones on the basis of a case history is unacceptable) and to provide the practitioner understanding of what tissues require support, and how much support; the individual nature of adrenal fatigue dictates that there is always a requirement to tweak recommendations to best suit the client and anything that removes the guesswork is a very valuable tool. Lifestyle recommendations – avoid caffeine/alcohol/tobacco/sugar, provide sufficient time for sleep, balance your blood sugar levels with regular small meals and avoid all unnecessary stress – remain similar regardless of the specific pattern of adrenal fatigue, although the results of the ASI represent a vital basis for all the specific interventions that provide such powerful improvements in adrenal fatigue.

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About the Author:
Marek is a London nutritionist and the pioneer of the Combined Allergy Test. He is also an elite personal trainer with studios in West London and Basingstoke. He has been recognised as one of the top trainers in the UK and counts world champion athletes, cover models and TV personalities amongst his clientele. His website is


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