Tired All the Time: What Chronic Fatigue Really Is, and What “Adrenal Fatigue” Gets Wrong

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Hi, I’m Helen. I spent more than ten years trying to get a diagnosis before I was told in 2020 that I have panhypopituitarism, and I also live with dysautonomia and chronic fatigue. I’m a mother and partner who still has to feed a family on days my body won’t cooperate, so everything I share here is something I’ve worked out and use myself.

Fatigue is the symptom I get asked about most and the one that is hardest to explain to people who haven’t lived with it. I don’t mean tired after a bad night. I mean the kind of tired that sleep doesn’t touch, where even a shower can feel like a day’s work.

If you are exhausted all the time and nobody can tell you why, you have probably come across the words “adrenal fatigue”. It is one of the most common explanations offered online for tiredness that sleep doesn’t fix, and it is also one of the most contested. I was given that label myself, so in this post I explain what it does and doesn’t mean, what chronic fatigue can really come from, what the research says about stress and exhaustion, and what I make of the natural options and supplements that are said to help.

What chronic fatigue can come from

Long-lasting tiredness is a symptom, not a diagnosis, and it usually has more than one cause behind it. The causes that come up most often are poor sleep, depression, thyroid disease, anemia or medications. Sleep apnea, where breathing repeatedly pauses overnight, is another one doctors consider. In my experience, though, true adrenal insufficiency is not always on the list of things that get looked for.

One of the rarer causes on that list is adrenal insufficiency (Acıbadem International), where the adrenal glands, the small glands that sit on top of the kidneys, don’t make enough cortisol. I have it, and I take cortisol every day to replace what my body can’t make.

“Adrenal fatigue” versus the real thing

Online you will see “adrenal fatigue” described as adrenal glands that get worn out by long-term stress and stop producing enough cortisol. It sounds sensible, and I understand why it appeals to people who are exhausted and being told their tests are normal. But no reputable medical organization, including the Endocrine Society, recognizes adrenal fatigue as a real disease. A 2016 systematic review of 58 studies found conflicting results and concluded there is no substantiation that adrenal fatigue is an actual medical condition (BMC Endocrine Disorders).

Adrenal insufficiency, on the other hand, is a diagnosable condition. It is confirmed with blood tests, and the early-morning cortisol level and ACTH, the brain’s signal telling the adrenals to work, are measured together (South African Medical Journal). It is also potentially dangerous if left untreated. I know this from the inside, and it is the reason I worry when someone with serious symptoms is told it’s “just adrenal fatigue” and the real cause goes unlooked-for.

That doesn’t make the exhaustion of chronic stress imaginary. Long periods of stress, poor sleep and overload do wear a person down, even when the adrenal glands themselves are working fine. The cause is usually somewhere other than the adrenals.

Just because adrenal fatigue and adrenal burnout aren’t real diagnoses doesn’t mean that what people feel under long-term stress isn’t real. Burnout, the better-recognized term for it, is described as a chronic depletion of a person’s energy resources caused by chronic stress, and every definition of it treats exhaustion as the main feature (narrative review). People who seek help for it typically report longstanding fatigue, sleep problems and trouble with memory and concentration.

The research on cortisol is messier than the wellness world makes it sound. One review found that activity in the body’s stress systems tends to be higher in the early stages of chronic stress and may drop the longer it goes on, but the studies contradict each other and high-quality research is still lacking (review). A small study comparing 22 burnout patients with 23 healthy people found higher cortisol in the first hour after waking in the burnout group, which the researchers read as a possible sign of sustained activation (study).

What this looked like for me

Before I was diagnosed, many doctors told me I had “adrenal fatigue” because of my symptoms. I have panhypopituitarism (PHP), which means my pituitary gland, the small gland at the base of the brain that tells the rest of the body’s hormone glands what to do, doesn’t work properly. That in turn causes secondary adrenal insufficiency (SAI), where my adrenal glands can’t make cortisol because they never receive the signal to do so. None of us knew any of that at the time, so for years I was given supplements meant to boost my body’s natural energy systems.

Looking back, we were wasting both money and time. Over-the-counter supplements are meant to support something your body is already producing, but if nothing is being produced, there is nothing for them to work with. Multiply a thousand by zero and the answer is still zero. I wasn’t low on a nutrient, I was missing the hormones entirely.

At one point a doctor did test me for Addison’s disease, which is primary adrenal insufficiency, where the adrenal glands themselves are the problem. My results came back fine. She came so close, but she later told me that doctors get very little training on conditions like SAI, so they aren’t equipped to think of it, and I spent roughly another ten years searching for help. A Cleveland Clinic survey found most primary care physicians wanted more education on adrenal insufficiency.

For years I also used an over-the-counter allergy spray that, as I later learned, contained a small amount of a corticosteroid, a medication related to cortisol, and my endocrinologist told me it had been protecting me far more than I realized, although it was entirely by accident and not something I would suggest as a solution.

Natural ways to ease fatigue

Outside of prescribed medication and supplements, the things that still make a difference for me are the unglamorous ones. I pace myself and spread tasks across the day so I don’t spend a whole day’s energy in one go. I keep my sleep times as regular as I can, I eat at regular times so my energy doesn’t crash, and I go for short, gentle movement when my body allows it. I also watch my stress, because it shows up in my energy sooner than I’d like.

Supplements that are said to help

Where long-term stress, poor sleep and rushed meals have left someone low in the nutrients the body uses to make energy, supplements may help. I treat supplements with caution, and the honest summary is that they mostly help when you are low in something.

I buy NOW supplements when I can because it’s a brand I trust that I can get in South Africa, and most of the supplements I link here are theirs. NOW doesn’t sponsor me or this post and has never sent me anything, and the only thing I earn is the Amazon affiliate commission I mention above.

• NOW Energy Boost:
• Vitamin D: Some sources claim that fatigue is a common symptom of low vitamin D and that too much can be toxic (GoodRx), which is why I would test my level first.
• Iron: Low iron can leave you feeling tired, and iron supplements are meant for people with an iron deficiency or who don’t get enough from food (University of Florida Extension). Some sources claim that if you don’t have anemia or low iron, there’s no evidence that taking iron will help fatigue (GoodRx). A ferritin test, which measures stored iron, shows where you stand.
• B vitamins (especially B12): The NIH says B12 doesn’t provide energy benefits in people who get enough from their diet, although a deficiency can make you feel tired or weak (NIH fact sheet). Vegetarians, vegans, older adults and people on some stomach-acid or diabetes medications are more likely to be low.
• CoQ10: A compound your cells use to make energy. Some sources claim it works best when cell energy production is already compromised, and the evidence is weaker in healthy people (Superpower).
• Cal-Mag: I take it to help with the cramps I get from my cortisol replacement. People also often mention it for energy and sleep, though I haven’t come across strong research on that, so I can’t point to a source.
• Rhodiola and ashwagandha: These are adaptogens, herbs said to help the body handle stress. Some sources claim that 200 mg of ashwagandha for 12 weeks left people less fatigued, but more research is needed, and that for rhodiola there’s not much evidence for any health issue, though one study of 100 people with chronic fatigue found it reduced fatigue (GoodRx).

One warning matters most to me. Some sources claim that products sold as “adrenal support” can contain real steroid hormones that may suppress your own cortisol production (Acıbadem International). For anyone on thyroid or steroid medication, I would run a supplement like ashwagandha past the prescribing doctor first, since herbs can interact with medication.

Sources

Adrenal fatigue and adrenal insufficiency

• Cadegiani FA, Kater CE. Adrenal fatigue does not exist: a systematic review. BMC Endocrine Disorders, 2016.
• Article on adrenal fatigue, South African Medical Journal, vol. 108, issue 9.
• Acıbadem International, Adrenal Fatigue: Why Endocrinologists Reject the Diagnosis.
• Cleveland Clinic, Adrenal insufficiency: continuing education needed for primary care physicians.

Chronic stress and burnout

• Endocrine and immunological aspects of burnout: a narrative review.
• The hypothalamo-pituitary-adrenal axis and the autonomic nervous system in burnout.
• Study comparing 22 burnout patients with 23 healthy people.

Supplements

• NIH Office of Dietary Supplements, Vitamin B12 Fact Sheet for Consumers.
• University of Florida Extension, iron.
• GoodRx, best energy supplements for chronic fatigue.
• GoodRx, vitamins and supplements for an energy boost.
• Superpower, supplements for energy.

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I’m sharing what works for me, not medical advice. Please read the Disclaimer and the Affiliate Disclosure.