In our last series of episodes, we talked about polycystic ovarian syndrome (PCOS).
We have categorized PCOS into three types:
Classic has the majority of all the symptomatology that pertains to PCOS.
Common has some but not all of the symptoms of PCOS.
Concealed PCOS is often missed. What we have found is that the Concealed type of PCOS has a lot of properties and similarities with adrenal fatigue.
In this episode, we are going to talk about the similarities between PCOS, and especially the Concealed type and Adrenal Fatigue. We are also going to explain the differences between PCOS and Adrenal Fatigue.
Let’s differentiate between Concealed PCOS, Adrenal Fatigue:
As mentioned, the Concealed type of PCOS is not often picked up on. It is often mistaken for Adrenal Fatigue/Dysfunction. These are the women that have been to many doctors looking for answers. Their symptoms seem to develop or get worse when they hit their late 30’s to early ’40s. Because at this time, the female hormones can be changing due to perimenopause, and the body cannot maintain balance, so the PCOS and Adrenal Fatigue symptoms start manifesting. This is what you typically see in a
Concealed PCOS Symptoms:
- May have a child, so it looks like there are no fertility issues
- Regular periods but might be more painful and cramping with terrible PMS
- Anxiety and fatigue: feeling wired and tired at the same time
- Thin Hair
- Slender until mid 30’s to early ’40s. Then it feels like they gain weight overnight. Especially in the belly area. No matter what they do, eating less/exercise more, the weight doesn’t budge.
What is Adrenal Fatigue?
This name can be misleading. We actually like the terminology, Adrenal Dysfunction. Because it is the dysfunctional activity of the adrenal glands that creates all the symptoms associated with “Adrenal Fatigue.”
Let’s explain a little more about Adrenal Dysfunction. Like we mentioned earlier, the adrenal glands are not “fatigued” per se. They are healthy tissue and healthy glands. It is the hormonal secretion and function of the adrenals glands which are degraded or dysfunctional. We have all heard about cortisol. Cortisol is essential for life. But secreted inappropriately, can cause a lot of symptoms, specifically ones of Adrenal Dysfunction. Cortisol is supposed to be highest in the morning and then will slowly drop and will be very low at night. This allows us to be awake in the morning and daytime, but able to sleep at night. In Adrenal Dysfunction, you will see what is called a “Reverse Diurnal Curve” of cortisol. Meaning the cortisol is low in the morning and can be especially low in the afternoon. This causes morning tiredness and afternoon crashes in energy. Then the cortisol will rise at night, causing one with Adrenal Dysfunction unable to sleep.
In Adrenal Dysfunction, you will also see some of the other hormones released from the adrenal glands to be off. For example, you will see low pregnenolone and low DHEA in Adrenal dysfunction. With resulting low levels of Testosterone in the body due to the drop in adrenal hormones.
Why would one confuse PCOS with Adrenal Fatigue?
It is easy to understand how one would be confused whether they have Concealed PCOS or Adrenal Dysfunction.
Some of the common overlapping symptoms are:
- Weight gain and having an extremely difficult time losing weight
- Brain fog
- Menstrual irregularities
- Trouble sleeping
- Mood issues
But there are differences. And it is common to have both. Many people with hormonal imbalances such as hypothyroid, Hashimotos, Perimenopause, and more can have Adrenal Dysfunction at the same time. But In this case, it is important to differentiate between PCOS and Adrenal Dysfunction. As the treatment plan can differ between the two of them. You will see a lot of overlapping of the symptoms of PCOS and Adrenal Dysfunction. But the hormonal imbalance can be different between the two. That can cause an increase in symptoms if you try to treat the Concealed PCOS as you would Adrenal Fatigue and vice versa. Let us further explain this.
With typical Adrenal Dysfunction, you will see lower levels of some of the adrenal hormones. In the next episode, we will go over testing and diagnosis of Adrenal Dysfunction.
But this is what you would typically see:
- Low pregnenolone
- Low DHEA-sulfate
- Low Testosterone
- Disrupted diurnal curve of cortisol: low in the morning and rises at night
With the Concealed type of PCOS, you will see a bit of a different picture:
- Low pregnenolone
- High normal or just over the edge of normal range of DHEA-sulfate
- Moderate to high normal levels of testosterone.
- Disrupted diurnal curve of cortisol: low in the morning and rises at night
In Adrenal Dysfunction, you might try to raise DHEA, Pregnenolone, and Testosterone. A lot of docs will give patients with Adrenal Dysfunction supplementation and prescriptions of DHEA, Pregnenolone, and Testosterone. You can see this would not be a good idea in the Concealed type of PCOS. That would only raise their levels of DHEA and Testosterone, making their symptoms worse.
While there are many of the same symptoms in PCOS and Adrenal Dysfunction, there are differences, which is why it is important to differentiate the two.
We have a free hormone video series on PCOS, Perimenopause, Menopause, and Hypothyroid.
In both PCOS and Adrenal Dysfunction there is weight gain and a very difficult time losing weight. We also have a free weight loss guide that can help: Keto-Carb-Cycling Program (KCCP) that you can download at progressyourhealth/kccp.com.
PYHP 066 Full Transcript:
Dr. Maki: Hello everyone. Thank you for joining us for another episode of the Progress Your Health Podcast. I’m Dr. Maki.
Dr. Davidson: I’m Dr. Davidson.
Dr. Maki: So in this episode, we’re going to transition from going– from talking about PCOS specifically the concealed type in transitioning into talking about adrenals, and comparing the two of those because sometimes they kind of get misconstrued. Sometimes people think they have PCOS when it’s really not and vice versa.
Dr. Davidson: Exactly. So with PCOS Polycystic Ovarian Syndrome in the past episodes we broke it down into the three types that we typically see in our practice over options 2004. Is we have the classic PCOS which has pretty much all the symptoms you can’t miss it. The common which has some of them can be missed but most often you can find it. Then the concealed which honestly the concealed PCOS is missed a lot. You see people going from doctor to doctor trying to find answers and that’s where we get people coming into us saying, I think I have adrenal fatigue or do I have PCOS? I don’t know. PCOS or adrenal fatigue they’re not really sure and of course, Dr. Maki and I were talking about this little earlier this morning is you can have adrenal fatigue and Hashimoto’s. You can have adrenal fatigue in PCOS.
You can have adrenal fatigue in menopause. Adrenal fatigue isn’t by itself. They can go concurrently but one of the main aspects in differentiating whether is that concealed type of PCOS or adrenal fatigue is sometimes a treatment plans for both of those are completely different. So you wouldn’t necessarily want to treat somebody with the concealed PCOS as your typical adrenal fatigue because you can actually exacerbate the symptoms. So just to back up, let’s talk a little bit about what the concealed PCOS is, for those of you that might not have listened to the previous podcast.
Dr. Maki: Right, right, right. We say it on the last one too. We don’t necessarily agree with the term PCOS for the concealed type but it does have some of the characteristics both in symptom and lab testing. The reason why it gets missed so often is because it’s not like the classic, right. It doesn’t have all the textbook diagnosis that it’ll show up. But there are some subtleties to it which is if what you’re looking for, both on how the patient presents. With the lab show, it starts to kind of paint that PCOS kind of picture. We’re just trying how to kind of differentiate to see which one—of anyone listing out there, which one you fall into. Now it’s certainly possible if you have the classic or the common that you could have. I just said you could have both of them but you’re not going to necessarily have adrenal dysfunction and concealed PCOS not necessarily at the same edge probably more than like we going to be one or the other or a component of one on the other.
Dr. Davidson: Yes, so that way– sure you can treat both of it but we’ll get into it a little bit more on why you want to– you wouldn’t want to just automatically treat somebody with the concealed PCOS or Polycystic Ovarian Syndrome with just your typical adrenal fatigue treatments. We’ll get into that a little bit. But the concealed type mainly you know people– the women seem to do pretty well. They do pretty well as teenagers and in their 20’s and like we talked about in the last episode, the concealed PCOS is a little but more like adrenal fatigue driven. Where it’s almost like they’ve been under a lot of stress and they’re maybe predisposed to PCOS but it’s not manifesting but you put a tremendous amount of physical or mental stress on thus female and then you’ll see that concealed PCOS start to rear its head right around their late 30’s and early 40’s. Because on our 40’s or early 40’s, I’m maybe more in my mid to late-ish 40’s. But we all know that those hormones changed.
When you’re 40’s your hormones are changing, late 30’s your hormones are changing, so as those female hormones are changing then the body can’t maintain or buffer some of the symptoms and so you see these– that’s where we get these women therein they’re late 30’s and they’re saying, “You know what I think I have PCOS but I never was told that.” They might even have a child because typically in PCOS there’s fertility issues but, this woman might have a child, they might even have regular periods or maybe missing a period here and there. So it looks a little bit like PCOS because they’ll have the thin hair, they’ll have the irritability, they’ll have the weight gain, they might they’ll have the terrible PMS but not completely like you would see in a classic PCOS.
Dr. Maki: Yes right. Honestly, we might be kind of splitting hairs a little bit, trying to differentiate between adrenal dysfunction. You and I like the term adrenal dysfunction more than we like to term adrenal fatigue. But adrenal fatigue is kind of like this implied umbrella term for adrenal issues but it doesn’t always manifest as your adrenals are just exhausted. I think from an endocrinology perspective, you go to an endocrinologist they’re going to reluctantly test your adrenals. They might do an ACTH test which is a brain hormone. They might do a blood cortisol test which is, we don’t prefer them. We’ll talk about that on the next episode. We’re going to talk about some testing. Everyone falls within a normal range on those. We’re looking at some– literally looking up some diagnosis codes and really there is nothing. There’s two ends of the spectrum. You have Cushing’s which is an overproduction of cortisol which would be a hyper cortical. You have Addison’s disease which is really true a diagnosable adrenal insufficiency. Those are both fairly rare problems and then there’s nothing else in between.
So adrenal dysfunction and adrenal fatigue everything that we’re talking about is kind of like this limbo-land. I know you talked about pre-menopause is being this limbo-land of hormones but really adrenals are there’s these huge expands between two end of the spectrum and nothing in between. Now, maybe what we’re talking about is concealed PCOS type is part of the middle ground there somewhere. Adrenal dysfunction is a middle ground in there somewhere where people are being categorized a little bit better so we can understand what’s going on, then hormonally. Then you and I is the practitioner, other practitioners are able to help them, feel better and function normally on daily day basis.
Dr. Davidson: Yes. We’ve been treating patients with adrenal fatigue for years and over time we both have talked about this endlessly that is not– you know the word adrenal fatigue just really isn’t the right term because it’s not that the adrenals are necessarily fatigued like they’re so tired and they need to go on vacation or something. But that’s really more–
Dr. Maki: Although everyone probably does need a little more of vacation. As you said earlier about all the stress they have, they probably do need a vacation.
Dr. Davidson: Let’s all go in vacation. Let’s make it a plan.
Dr. Maki: Yes right.
Dr. Davidson: All of us together now. But no truly it’s more of a dysfunction. Your adrenal glands are healthy, they’re not dying. You don’t have adrenal glands, you wouldn’t be alive. But the adrenal glands are healthy tissue it’s just there output of hormonal production is dysfunctional. That can be do to internal or external circumstances over time, chronic stress. So that’s why we like to call it adrenal dysfunction. Like Dr. Maki was talking about– you know, yes you go to your endocrinologist and tell me you have adrenal fatigue, they’ll just look at you cross-eyed and say stop paying out on Google which sort of you know [chuckles] which is totally dismissing somebody.
Dr. Maki: Yes right. Like all the stuff that we talked about when it comes to the adrenals like it just make believe. Like people don’t have symptoms that are really– now granted, this why this so unusual from a doctor’s perspective like cortisol and your adrenal glands plays huge role in how we look and feel on a day to day basis, right. Everything really at the end of the day comes down to our response to our environment and the adrenal glands and the brain of course, you know, that’s what they call the HPA Axis, the Hypothalamic Pituitary Adrenal Axis. How the brain the adrenals are connected and how it basically interprets the world around you.
Now, you can’t tell me that that is– now I think you and I were kind of speculating. Maybe this doesn’t get talked about a lot because there’s really no medications that you can give for this type of dysfunction, right? So then it’s just gets ignored. Now that’s probably why there’s no ICD 10 insurance building codes for this because there’s no treatment for it. So then they just kind of brush it off and make you seem like a crazy when in reality it’s just a little bit of ignorance. Endocrinology in our opinion really has evolved very much in the last 70 years.
I think that in a functional medicine space, this is where you and I often don’t really need an actual diagnosis, right? We can look at someone’s symptom picture, maybe get some functional testing. We’ll talk more about that on the next episode. That helps us kind of point in a particular direction and then differentiating between these different things that we’re talking about that are not real diagnosis, right. I can see why from a person’s perspective, going your doctor, you don’t feel very good, you don’t feel like yourself. You go to your doctor, he’s supposed to help you and they make you almost feel worst because there– it’s almost like they blame it on you when it’s really their lack of knowledge that because they don’t even consider that these things are even real problems.
Dr. Davidson: But like I said, your adrenal glands with adrenal dysfunction are healthy. They see a healthy person, you know, a lot of endocrinologists deal with a lot of very unhealthy people with diabetes type 2 or diabetes type 1. So it’s just– it is kind of a flood system and I’m sure all of you listening, understand, health care really has so many limitations and it’s such a flood system. But with adrenal dysfunction, we absolutely 100% believe in it and like we we’re going to go into the testing on the next episode but it really is partly what’s about hormones that the adrenals are secreting. So for example the adrenals, we all know secretes cortisol. But cortisol is secreted in a diurnal fashion over the day. So it’s highest in the morning, it starts to come down and then it slows it at night so you can go to sleep. What you see in adrenal dysfunction is the cortisol is low in the morning and then you do see the cortisol come up at night. That’s pretty classic for most people with adrenals dysfunction. But you also see that with that concealed type of PCOS. Actually with pretty much all 3 types of PCOS because of the burden on the hormones is you see that adrenal dysfunction can kind of manifest that way as well.
Dr. Maki: Yes right. What you’re talking about that what it’s called the reverse diurnal occur, right. You supposed to be high in the morning between 5 o’clock in the morning. Supposed to be low at night, usually between midnight and 2 in the morning. How many people that we deal with on a regular basis are having a really hard time waking up and they can’t go to sleep or they can’t stay asleep all night. That is kind of your classic representation, your classic manifestation that there’s a little a bit of adrenal problem going on. Now, is that diagnosable? I mean how many people have sleep issues across the country? Probably tens of millions of people are having sleep issues and your adrenals don’t really get talked about much in that conversation. You and I believe that it is the cornerstone of those issues. That’s why with every patient that we deal with, we take sleep as a really high priority because that’s the only way those adrenals are going to begin to rebounds themselves.
Dr. Davidson: Yes. So definitely with PCOS and adrenal dysfunction, you see that sleep issue. They’re tired in the morning, they can’t sleep at night. Like I’ve mentioned earlier there’s weight gain with really tough time losing weight. You see the fatigue, you see the irritability, you see the– there can definitely be menstrual irregularities, the brain fog, the mood issues. So now you’re saying well it almost sounds like PCOS and adrenal fatigue are the same things. But that’s where there’s a little bit of a catch. So yes, the diurnal curve of that cortisol is degraded in both concealed types of PCOS and with adrenal dysfunction. But one thing that we noticed with those PCOS women especially the concealed type, is they do have a little high normal or just over the edge of normal of those androgens. So you’ll see the testosterone a little bit high normal. You’ll see that DHEA a little bit high normal, if not a little bit high. Now typically with adrenal fatigue, because DHEA is secreted mainly from the adrenal glands with adrenal fatigue, adrenal dysfunction is you will see typically low DHEA levels, low testosterone, low, low normal testosterone levels that you wouldn’t necessarily see in that concealed type of PCOS.
Dr. Maki: Yes right. So really, as what we are talking about this, right. They really the distinction comes down. To maybe not necessary how the patient or the person manifest but your clinical presentation is just really about the lab testing. That’s why for pretty much all women from their teens to their 60’s we are testing their DHA prenatal testosterone because you can’t sometimes– for what you just said, you can’t predict what are those numbers are going to be high or low. You might think and I’ve seen– I know we both seen this many times. The one that you think their DHA is going to be really high or high normal, it’s like 75, right. Their testosterone you might think that it would– should be really low, and now it’s– that’s also 75. It doesn’t always match what their presentation is until you look at those labs and you see, what kind of what’s going on. Of course your better idea.
Dr. Davidson: Which like we mentioned we’re going to talk about the labs in the next episode but just to kind of make a little more clear, you know this– you know years ago, I was noticing– you know, I’d have a patient come in to see me and they have adrenal– they say I have adrenal fatigue. They’ve been to numerous doctors and they’re still looking for help. What we would see is these patients would say, “Well I was at– I was being treated for adrenal fatigue from my– from this other doctor and they gave me testosterone and I felt horrible.
But they told me I needed it or they gave me DHEA and I broke out like crazy and felt terrible.” So that’s what it kind of lead to this little bit of distinction because then I say well, of course, they’re not taking that testosterone or DHEA anymore. As I would test their levels and they actually had kind of high normal. So then over time we kind of figured out, well, sure this person might have aspects of adrenal dysfunction but they have that concealed type of PCOS. That’s never picked up by a practitioner so you give this person that has high normal DHEA, high normal testosterone and you give them more. Of course, they’re going to feel horrible. So that was kind of why my kind of basis for doing this podcast today because, sure, we’re splitting hairs that seems like the same. PCOS concealed seems just like adrenal dysfunction but in some ways, you want to be careful about the treatment because you could make somebody worse by giving them those androgens then not doing the testing.
Dr. Maki: Yes and really the– we are maybe splitting hairs a little bit but it’s something that we have noticed and really like you said in that 30, mid 30’s to mid 40’s range, honestly we could call it perimenopause at the same time. So there’s kind of three things happening there that as the female hormones, there estrogen, progesterone are starting to change, of then all of a sudden you get this surge of the androgen to DHA in the testosterone. We see that quite often. They’re the ones that like you said they go to the anti-aging clinic or another type of hormone clinic and they usually end up doing worse because they– you can’t give them estrogen yet because they’re still menstruating, right. So of course doctors are prescribing them way too much testosterone. They usually do– they don’t perform very well that way. Testosterone in our opinion for women is kind of like the icing on the cake. You don’t start with testosterone, you don’t start with DHEA, you kind of end with those because those are really powerful hormones and those are really not the hormones that make women, women. Those are hormones that are– they are very powerful but you have to be kind of careful and delicate with them to have the response that you want.
Dr. Davidson: Exactly. So with this podcast, we wanted to just sort to differentiate a little bit because that is probably one of the top questions we get is, do I have adrenal fatigue? Or do I have PCOS? My gynecologist says I have PCOS but I don’t think I do and they don’t know what adrenal fatigue is. So people are confused and sure you can have a little bit to both but we just want to kind of differentiate that sometimes that treatment might be different. So you want to test it but like Dr. Maki said is usually when comes in and you can get the symptoms, you can also get their past history, you can pretty much pick up like you know what? I think they might be a concealed PCOS. Let’s treat this just a little bit differently than you would a typical adrenal dysfunction patient. But in both respects which is really important and probably the top number question is they want to lose weight. Again, it’s almost like with both. With adrenal dysfunction and especially with the concealed PCOS, it’s like, I have the women come in, I was fine to my 20’s, I was great 30’s and then all of a sudden I have a belly. I’ve never had a belly in my whole life and where did this belly come from. It’s almost like they gained 12 pounds overnight.
Dr. Maki: Yes right. We are now going to get into the cortisol physiology but again that’s usually where their stress level is the highest and for whatever reason the body just the size that it wants to– when it’s cortisol driven it wants to redistribute weight around the midsection. Usually, that’s why it starts happening in the 40’s is when those female hormones are usually declined a little bit. They tend to act as buffers or this very powerful insulin cortisol hormones that like you said earlier, we can’t live without them. Those are such a major part of our physiology that they kind of– in some ways kind of run a mock a little bit when you don’t have the female hormones or the male hormones on the counterpart to balance that out.
Dr. Davidson: Yes. So just on a side note because we’re very much into hormonal weight loss is we do have a guide that we’ve created. A free weight loss guide called the Keto Carb Cycling Programmer. We like to abbreviate it as KCCP and you might’ve heard about it on other podcasts because we want to give it to everybody. So if you’re interested in it, we use it a lot with people with adrenal dysfunction and especially with PCOS because the way it’s modified is to kind of help with that– because it’s all that hormonal leaking. It’s not like, these women that come to see me with the concealed type of PCOS, they’re not eating ice cream and junk food of anything and they’re doing the opposite to that and they’re not seeing any changes. So if you’re interested in the KCCP, you can download it at progressyourhealth.com/kccp
Dr. Maki: Yes just progressyourhealth.com/kccp, just a simple enter your name and email and you’ll get access to it right away. The keto part I will say about it. The keto part is optional. You don’t have to go into keto and some people do fine with keto, some people do terrible with keto. Keto really is more about having a little bit more of a lower carb phase. But it doesn’t have to actually be keto. The carb cycling part is intentionally raising calories on a strategic basis. The strategic basis is based on your stress levels, based on your activity level, how much exercise you’re doing that dictates how frequently you raise your calories and then it just kind of add some flows overtime. We kind of designed it specifically for these types of situation, right.
Women that are at this point in their life they cannot do what they used to do on their 20’s, right. It does not work anymore of just eating less and exercising more. That when you’re 25, but once you get beyond the age of 35 and have had a few kids, that no longer works. You have to take a little bit of a different strategy and that the big mistake that we see all the time is that, everyone is under-eating overtime for far too long. Honestly based on what we’re talking about adrenal dysfunction increase more of that and it almost this like a self-fulfilling prophecy kind of creates exactly what everybody’s trying to fix. So there’s a section in there about calories. That’s important you don’t have to count calories but you need to be calorie aware. It’s kind of designed that way based on exactly our patient population that hopefully get you going in the right direction. So, Dr. Davidson do you have anything else to add about the difference between concealed PCOS which is our own creation, right. That’s something that we came up with on our own, you’re not going to find that online any works that from us and adrenal dysfunction. You have anything else to add about them?
Dr. Davidson: No, you’re right. I mean a lot of doctors have their own types of they’ve seen and that’s great. It’s just this is kind of the types that we’ve been broken it down to as we’ve commonly seen because for example, I’ll treat a classic PCOS case completely different than a common or as we talked about here with that concealed. So, no. This was great.
Dr. Maki: Yes, all right. Till next time I’m Dr. Maki.
Dr. Davidson: I’m Dr. Davidson.
Dr. Maki: Take care. Bye-bye.
Dr. Davidson: Bye.