Acupuncture, Herbs and Nutrients for Enhancing Endurance and Alleviating Fatigue

by Barbara Connor, M.Ac., L.Ac.

This article reviews studies on the benefits of acupuncture, herbs and nutrients in building energy and reducing fatigue. I also describe how Traditional Chinese Medicine addresses these issues and how the adrenals and thyroid gland are involved. I hope you find this article helpful in your quest for optimal health.

Table of Contents
Introduction
Studies on the Effects of Acupuncture and Moxibustion on Fatigue and the Adrenals
List of Herbs and Nutrients for that Enhance Endurance and Alleviate Fatigue
Studies on Herbs and Nutrients that Enhance Endurance and Alleviate Fatigue
Traditional Chinese Medicine and Fatigue
The Role of the Adrenals
Thyroid – Adrenal Relationship
References

Introduction

Fatigue is one of the commonest complaints reported in primary care, constituting up to 20 % of all presentations and the principal reason for consultation in 5-7 % of cases. (Basu et al 2016)

As pervasive and debilitating as fatigue is, the etiology of fatigue remains poorly understood. Fatigue is often described by patients as a lack of energy, mental or physical tiredness, diminished endurance, and prolonged recovery after physical activity. Fatigue is a hallmark symptom of mitochondrial disease, making mitochondrial dysfunction a putative biological mechanism for fatigue. Mitochondria (the “power house” of the cell) have an essential role in energy production through the process of oxidative phosphorylation where nutrients are converted into adenosine triphosphate (ATP), which powers many of the cells’ activities. (Filler et al 2014)

Experienced fatigue may be defined as an overwhelming sense of tiredness, lack of energy and feeling of exhaustion. More specifically, muscle fatigue with exercise intolerance is a multifactorial process characterized by failure to maintain an expected level of force during sustained or repeated muscle contraction, and is considered a common symptom of mitochondrial diseases. (Mancuso et al 2012)

Possible insights into the cause of fatigue may be derived from research examining the concept of ‘burnout’ – consisting of emotional exhaustion, cognitive weariness and physical fatigue. This state has been characterised by reduced hypothalamic pituitary adrenal axis responses, low grade inflammation and impaired fibrinolytic capacities, all of which have also been independently associated with cardiovascular disease. (Basu et al 2016)

Primary hypothyroidism is a relatively common disease, with a prevalence of 0.3%–5.0%. Despite apparently adequate thyroid hormone replacement, many hypothyroid patients still experience persistent fatigue and fatigue-related symptoms. (An et al 2016)

The most common cause of anemia worldwide is an iron deficiency. There are several causes of iron deficiency that vary based on age, gender, and socioeconomic status. The patient often will have nonspecific complaints such as fatigue and dyspnea on exertion. Treatment is a reversal of the underlying condition as well as iron supplementation.  (Warner & Kamran 2017)

Cancer‐related fatigue is characterized by significant physical, emotional, and/or cognitive exhaustion, which is disproportionate to the activity level and interferes with usual functioning in patients with cancer. Cancer‐related fatigue is one of the most prevalent symptoms experienced by patients with cancer, both during and after treatment. (Neefjes et al 2017)

Treatment of all types of fatigue should include a structured plan for regular physical activity that consists of stretching and aerobic exercise, such as walking. Short naps are proven performance enhancers. (Rosenthal et al 2008) One study found that sleep quality but not quantity predicted an increase in daily vitality.  (Schmitt et al 2016)

Studies on the Effects of Acupuncture and Moxibustion on Fatigue and the Adrenals

• Both acupuncture and moxibustion improved fatigue in  chronic fatigue syndrome (CFS) patients, but moxibustion was more effective. The possible mechanism of the intervention may be through activation of the vagus nerve. Moxibustion was more effective than acupuncture in long-term treatment of CFS. (Shu et al 2016)

• Electroacupuncture at ST 36 and SP 6 can mitigate the adrenal cortical inhibition induced by etomidate a short-acting intravenous anaesthetic agent and can reduce the secretion of catecholamines during surgery. (Yu et al 2014)

• This study revealed that Shenshu (BL23), Ganshu (BL18), Qimen (LR14), Jingmen (GB25), Riyue (GB24), Zangmen (LR13), Dazui (DU14) and auricular concha region (ACR) are the specificity acupoints; and Gallbladder, Liver and Du Channels were the specificity Channels. The acupoints on Gallbladder Channel and the acupoints innervated by the same spinal cord segments as the adrenal gland demonstrated dramatic effects. This study provides a new platform to further explore acupoints specificity in the regulation of hypothalamic-pituitary-adrenal cortex axis (HPAA) activities. (Wang et al 2015)

• This study was a randomised controlled trial. Acupuncture shows great potential in the management of cancer-related fatigue. As a randomised trial with acupuncture is feasible and preliminary data shows significant improvements, it should be tested further using a large sample and a multicentre design. (Molassiotis et al 2007)

List of Herbs and Nutrients that Enhance Endurance and Alleviate Fatigue

• Ajuga turkestanica
• American ginseng
• Ashwagandha (Withania somnifera)
• CoQ10
• Creatine
• Eleutherococcus senticosus
• Ginger (Zingiber officinale)
• Green tea extract
• L-carnitine
• Maca
• Milk
• Panax Ginseng
• Ren Shen Yangrong Tang
• Resveratrol
• Rhaponticum carthamoides
• Rhodiola rosea
• Taurine
• Ursolic acid

Studies on Herbs and Nutrients that Enhance Endurance and Alleviate Fatigue

Ajuga turkestanica – Oral supplementation of phytoecdysteroids (50 mg/kg/day) for 28 days has been demonstrated to increase muscle strength and mass in young rats. However, additional studies are required to support the use of phytoecdysteroids as a therapeutic tool to maintain satellite cell competency in aged skeletal muscle. This study found that Ajuga turkestanica supplementation in aged mice increases Notch and Wnt signaling in triceps brachii muscle. If Notch and Wnt benefit skeletal muscle, then phytoecdysteroids may provide a protective effect and maintain the integrity of aged skeletal muscle. (Arthur et al 2014)

American ginseng – Data support the benefit of American ginseng, 2000mg daily, on cancer-related fatigue (CRF) over an 8-week period. There were no discernible toxicities associated with the treatment. Studies to increase knowledge to guide the role of ginseng to improve CRF are needed. (Barton et al 2013)

Ashwagandha (Withania somnifera) – The findings suggest that Ashwagandha root extract enhances the cardiorespiratory endurance and improves QOL in healthy athletic adults. (Choudhary et al 2015)

Ashwagandha (Withania somnifera) – The present study was designed and performed to assess the effects of Withania somnifera and Terminalia arjuna (Arjuna) on physical performance and cardiorespiratory endurance in healthy young adults. The authors concluded that Withania somnifera may be useful for generalized weakness and to improve speed and lower limb muscular strength and neuro-muscular co-ordination. (Sandhu et al 2010)

CoQ10 – Our study suggests that CoQ10 supplementation (500 mg/day) can improve fatigue and depression in patients with multiple sclerosis. (Sanoobar et al 2016)

CoQ10 plus NADH – The observations of this study lead to the hypothesis that the oral CoQ10 plus NADH supplementation could confer potential therapeutic benefits on fatigue and biochemical parameters in chronic fatigue syndrome. Larger sample trials are warranted to confirm these findings. (Castro-Marrero et al 2015)

Creatine – Of the approximately 300 studies that have evaluated the potential ergogenic value of creatine supplementation, about 70% of these studies report statistically significant results while remaining studies generally report non-significant gains in performance. No study reports a statistically significant ergolytic effect. For example, short-term creatine supplementation has been reported to improve maximal power/strength (5-15%), work performed during sets of maximal effort muscle contractions (5-15%), single-effort sprint performance (1-5%), and work performed during repetitive sprint performance (5-15%). Moreover, creatine supplementation during training has been reported to promote significantly greater gains in strength, fat free mass, and performance primarily of high intensity exercise tasks. Although not all studies report significant results, the preponderance of scientific evidence indicates that creatine supplementation appears to be a generally effective nutritional ergogenic aid for a variety of exercise tasks in a number of athletic and clinical populations. (Kreider RB 2003)

Creatine and sodium bicarbonate supplementation independently increase exercise performance, but it remains unclear whether combining these 2 supplements is more beneficial on exercise performance. The purpose of this study was to evaluate the impact of combining creatine monohydrate and sodium bicarbonate supplementation on exercise performance. Combining creatine and sodium bicarbonate supplementation increased peak and mean power and had the greatest attenuation of decline in relative peak power over the 6 repeated sprints. These data suggest that combining these 2 supplements may be advantageous for athletes participating in high-intensity, intermittent exercise. (Barber et al 2013)

Eleutherococcus senticosus – This animal study was designed to ascertain the anti-fatigue property of Acanthopanax senticosus (also called Eleutherococcus senticosus or Siberian ginseng) by load-weighted swimming test, sleep deprivation test, also to isolate and characterize the active constituents. The eleutherosides possess potent abilities to alleviate fatigue both in physical and mental fatigue. (Huang et al 2011)

Eleutherococcus senticosus – This is the first well-conducted double-blind, randomized, placebo controlled and crossover study that shows that 8-week Eleutherococcus senticosus supplementation enhances endurance capacity, elevates cardiovascular functions and alters the metabolism for sparing glycogen in recreationally trained males. Subjects cycled at 75% VO2 peak until exhaustion. (Kuo et al 2010)

Ginger (Zingiber officinale) – Stimulation of the hypothalamus pituitary adrenal axis in stressful condition alters plasma glucose, triglyceride, cholesterol, BUN and corticosterone levels. There is also alteration in the blood cell counts. Pretreatment with the extract significantly ameliorated the stress-induced variations in these biochemical levels and blood cell counts in both acute and chronic stress animals. The extract treated animals showed increase in swimming endurance time and increase in anoxia tolerance time in physical and anoxia stress models, respectively. Treatment groups also reverted back to increase in liver, adrenal gland weights and atrophy of spleen caused by cold chronic stress and swimming endurance stress models. The results indicate that ethanolic extract of Zinziber officinale has significant adaptogenic activity against a variety of biochemical and physiological perturbations in different stress models. (Lakshmi & Sudhakar 2010)

Green tea extract supplementation significantly reduced disease activity in lupus patients (p < 0.004); in addition, it significantly increased the vitality (p < 0.006) and general health (p < 0.01). (Shamekhi et al 2017)

L-carnitine – These results suggest that L-carnitine supplementation may be useful in alleviating fatigue symptoms in hypothyroid patients, especially in those younger than 50 years and those who have hypothyroidism after thyroidectomy for thyroid cancer. (An et al 2016)

L-citrulline – These results indicate that L-citrulline has a modest effect of improving muscle blood flow during submaximal exercise in older men. (Gonzales et al 2017)

Maca – Two fractions of polysaccharide MPS-1 and MPS-2 were extracted from Lepidium meyenii Walp. (maca) by water. The results indicated that both MPS-1 and MPS-2 presented dose-dependently positive effects on the fatigue related parameters. Additionally, MPS-2 has a better anti-fatigue effect than MPS-1. (Li et al 2017)

Milk – The present study showed that higher milk consumption was independently associated with higher cardiorespiratory fitness and lower BMI levels in Greek preadolescents. Dietary intakes of vitamin B2 and B12 intake derived from milk could provide a basis for interpreting these associations, especially when considering the key roles of these vitamins in substrate oxidation and energy production as well in haemoglobin synthesis and erythropoiesis. However, further research is needed in order to shed more light on the effects of the dietary intakes of vitamin B2 and B12, for which dairy products are among their major food sources, on several health status indices in children and adolescents. (Moschonis et al 2016)

Panax Ginseng – This is the first report that Changbai Mountain Ginseng (CMG, Panax ginseng C.A. Mey) CMG extract supplementation increases muscle mass, improves exercise performance and energy utilization, and decreases fatigue-associated parameters in vivo. The major component of CMG extract is ginsenoside Ro, which could be a potential bioactive compound for use as an ergogenic aid ingredient by the food industry. (Ma et al 2017)

Ren Shen Yangrong Tang (RSYRT) decoction, a soup containing 12 TCM herbs* – RSYRT therapy was safe and was associated with fatigue improvement in nonanemic cancer survivors, consistent with historical TCM clinical practice experience. Because of a possible placebo effect in this open-label study, decoction RSYRT warrants further study in randomized clinical trials to confirm its effectiveness for managing moderate to severe fatigue. (Xu et al 2015)

* Components of Ren Shen Yangrong Tang: Dangshen (Radixcodonopsis pilosulae; root of pilose asiabell; often replaces ginseng), Huanqi (Astragalus mongholicus),  Baizhu (Rhizoma atractylodes macrocephala; white rhizome of largehead atractylodes), Fuling (Poria cocos; Indian bread), Chenpi (Pericarpium citri reticulatae; dried tangerine peel) , Shengdi (Radix rehmanniae; root of rehmannia), Baishao (Radix paeoniae alba; white peony root), Danggui (Angelica sinensis; root of Chinese Angelica), Wuweizi (Fructus schisandrae; shizandra berry), Yuanzhi (Radix polygalae; polygala root) , Rougui (Cortex cinnamomi; cinnamon), Gancao (Radix glycyrrhizae; licorice)

Resveratrol – In this animal study resveratrol (RES) supplementation produced dose-dependent decreases in serum lactate and ammonia levels and creatine kinase (CK) activity and also an increase in glucose levels in dose-dependent manners after the 15-min swimming test. The mechanism was related to the increased energy utilization (as blood glucose), and decreased serum levels of lactate, ammonia, and CK. Therefore, RES could be a potential agent with an anti-fatigue pharmacological effect. (Wu et al 2013)

Rhaponticum carthamoides – Soviet and Russian athletes have used and still use rhaponticum to improve athletic performance, endurance, and recovery from intensive training. Regular use of this herb promotes the building of muscle tissue, enhances the excretion of uric and lactic acid, and stimulates blood flow to the muscles and brain. (Winston & Maines, Adaptogens : Herbs for Strength, Stamina, and Stress Relief; Healing Arts Press, 2007, page 189)

Rhodiola rosea – Chronic Rhodiola rosea supplementation significantly improved exhaustive swimming-induced fatigue in this animal study by the increased glycogen content, energy supply of lipogenic enzyme expressions and protective defense mechanisms. (Lee et al 2009)

Rhodiola rosea – The purpose of this double blind placebo-controlled randomized study was to investigate the effect of acute and 4-week Rhodiola rosea intake on physical capacity, muscle strength, speed of limb movement, reaction time, and attention. Acute Rhodiola rosea intake can improve endurance exercise capacity in young healthy volunteers. (De Bock et al 2004)

Taurine – Additional supplementation of Taurine with branched-chain amino acids would be a useful way to attenuate delayed-onset muscle soreness and muscle damages induced by high-intensity exercise. (Ra et al 2013)

Ursolic acid – Our findings suggest that ursolic acid may induce mitochondrial biogenesis through the activation of AMPK and PGC-1 pathways in skeletal muscle, thereby offering a promising prospect for its use to enhance exercise endurance and alleviating fatigue in humans. (Chen et al 2017)

Traditional Chinese Medicine and Fatigue

The area around CV-4 (Gate to the Original Qi) and CV-6 (Ocean of Qi) is called the Dan Tian. This is the energy center of the body which is concerned with the storage and distribution of energy, both Qi and Jing (essence). CV-4 is used mainly to strengthen the storage aspect of the Dan Tian. CV-6 corresponds more to the distribution aspect of the Dan Tian. According to Japanese acupuncture theory the Dan Tian is the center from which the energies emanate; and virtually all pathologies are seen as stemming from stagnation of the basic Qi.

Nutritive Qi may be related to the efficiency of tissues/cells to generate energy from nutrients, that is, the efficiency of mitochondria to generate ATP using fuel molecules. This postulation is strengthened by the earlier notion that the mitochondrion is regarded as the cell origin of Qi (energy). In this regard, nutritive Qi may also be Yang in nature. (Leong et al 2015)

In Traditional Chinese Medicine fatigue is a result of Qi or energy deficiency. Some of the more common syndromes of Qi deficiency include Yang Deficiency, Spleen Qi Deficiency and Kidney Yang Deficiency

Clinical Signs of Yang Deficiency:

Includes those of Qi deficiency ( pale face, a weak voice, slight sweating in daytime, slight breathlessness, tiredness, lack of appetite and an empty pulse) plus chilliness, a bright pale face, cold limbs, no thirst, a desire for hot drinks, loose stools, frequent-pale urination, a weak pulse and a pale wet tongue.

Useful Foods for Yang Deficiency:

Rice, sweet brown rice, oats, spelt, quinoa, corn, buckwheat and rye. Sunflower seeds, sesame seeds, fennel, dill, anise, caraway, carob pod, cumin, peanuts, chestnuts, cinnamon bark and pine nuts. Yellow onions, Chinese yam, Chinese cabbage, parsnip, winter squash, sweet potato, kale, leek, scallion, mustard greens and carrots. Chives, garlic, ginger, cloves, basil, rosemary, angelica root and parsley. Lychee, pumpkin, cherry, citrus peel, dates and raisins. Hot peppers and cayenne (caution:  use hot peppers and cayenne in small pinches or they can have a strong cooling effect). Walnuts (start eating one walnut a day, then add one more each day, not to exceed 20 per day). Coffee and cocoa (caution:  coffee and cocoa damage the yin in Yin deficient persons, and they are contraindicated in insomnia). Chicken, goat’s milk, beef, lamb, shrimp, mussels, fish (e.g., anchovy and trout). In general, use warming foods and methods of preparation.

Clinical Signs of Spleen Qi Deficiency

No appetite, abdominal distention after eating, tiredness, lassitude, sallow complexion, weakness of the limbs, loose stools, pale or normal colored tongue, empty pulse.  If Spleen Qi Deficiency gives rise to Dampness there may also be nausea, stuffiness of the chest and epigastrium and a feeling of heaviness.

Useful Foods for Spleen Qi Deficiency

(These should be cooked or taken at room temperature.  Limit the number of cooked fruits.)

Quinoa, parsnip, adzuki beans, black beans, pine nuts, garbanzo beans, cooked squash, cooked turnips, oats, rice, cooked cherries, cooked carrots, cooked leeks, mussels, shrimp, cardamom, black pepper, cooked strawberries, ginger, tapioca and custards, cooked yams, cooked onions, cooked rutabagas, cooked pumpkin, cooked peaches, dried litchi, cinnamon, arrowroot, dried figs, nutmeg, sweet potato, garlic, fennel. Moderate amounts of: honey, molasses, barley malt, maple syrup and raw sugar. Small amounts of: chicken, lamb, beef, turkey and anchovies.

Clinical Signs of Kidney Yang Deficiency

The Chinese medical syndrome that corresponds to decreased adrenal function is Kidney Yang Deficiency.  The clinical manifestations of Kidney Yang Deficiency are: soreness of the back, cold knees, sensation of cold in the back, aversion to cold, weak legs, bright-white complexion, weak knees, impotence, premature ejaculation, lassitude, abundant-clear urination, scanty-clear urination, apathy, edema of the legs, infertility in women, poor appetite and loose stools.  The tongue is pale, swollen and wet and the pulse is deep and weak.

Useful Foods and Spices to Warm the Kidney Yang:

Cloves, fenugreek seeds, fennel seeds, anime seeds. black peppercorn, ginger (dried preferred), cinnamon bark, walnuts, black beans, garlic, onions, chives, scallions, leeks, quinoa, chicken, lamb trout and salmon.

The Role of the Adrenals

The adrenal cortex is divided in three distinct zones: the outer, zona glomerulosa, that secretes mineralocorticoids (e.g. aldosterone), which regulate sodium and potassium homeostasis, the central, zona fasciculata, that secretes glucocorticoids (e.g. cortisol) which regulate energy and immune homeostasis and the inner, zona reticularis, that secretes sex steroids predominantly adrenal androgens (i.e. dehydroepiandrostenedione [DHEA] and DHEA-sulfate [DHEA-S]), with little intrinsic androgenic activity. (Papanastasiou et al 2017)

Adrenal steroidogenesis requires cholesterol as a substrate for steroid hormone synthesis and is controlled by two endocrine feedback circuits, the hypothalamic pituitary adrenal axis (HPA) that mainly regulates glucocorticoids and sex steroids and the renin-angiotensin-aldosterone system that mainly regulates mineralocorticoids. The adrenal medulla synthesizes and secretes catecholamines, which mainly modulate the body’s sympathetic response to stress.  (Papanastasiou et al 2017)

The serum concentration of DHEA-S is 300–500 times higher than that of DHEA and can be considered a circulating reservoir. In contrast to serum cortisol or DHEA concentrations, serum DHEAS levels do not exhibit a diurnal variation, as a consequence of a longer half-life. Therefore, serum DHEAS levels have been proposed to serve as a potential biomarker of adrenal function in different clinical settings. (Tsai et al 2017)

Cortisol is an established marker of the hypothalamic-pituitary-adrenal (HPA) axis the activity of which has previously been shown to increase acutely after high-intensity exercise. Indeed, stress hormones including cortisol have hyperglycemic effects, which makes measurement of this hormone relevant in the context of exercise. Insulin induces glucose uptake in fat cells and in muscle cells by translocation of the specific GLUT4 glucose transporters to the plasma membrane, and it also reduces glucose production in the liver. (Keselman et al 2017)

Salivary cortisol concentration was found to be directly proportional to the serum unbound cortisol concentration both in normal men and women and in women with elevated cortisol-binding globulin. The correlation was excellent in dynamic tests of adrenal function (dexamethasone suppression, ACTH stimulation), in normals and patients with adrenal insufficiency, in tests of circadian variation and randomly collected samples. (Vining et al 1983)

Dehydroepiandrosterone (DHEA) and cortisol mediate short- and long-term stress responses and enable physiological and behavioral adjustments necessary for maintaining homeostasis. Detrimental effects of chronic or repeated elevations in cortisol on behavioral and emotional health are well documented. (Kamin & Kertes 2017)

Cortisol, the primary hormone product secreted by the HPA axis, is considered to be a biomarker of HPA axis activity. Dehydroepiandrosterone (DHEA) is also secreted by the adrenal cortex and plays a pivotal role in the regulation of HPA activity, with effects that are opposite to cortisol at both peripheral and central levels. Past studies have found that mean cortisol levels exhibit an initial rise after awakening, referred to as the cortisol awakening response, followed by a decline in cortisol during the remainder of the day.  (Wilcox it al 2014)

DHEA-S levels are influenced by several factors, most importantly age and gender, and several studies reported low DHEA-S levels in patients with documented hypopituitarism and hypothalamic-pituitary-adrenal (HPA) insufficiency. In particular, in patients with a newly diagnosed large pituitary tumor, DHEA-S levels appeared to be a reliable prognostic parameter for the diagnosis of HPA insufficiency. (Fischli et al 2008)

It is well known that the sympathetic nervous system is closely involved in the regulation of the stress response. Psychological stress activates the sympathetic nervous system, and, in turn, catecholamines are released from the sympathetic nerve terminal and the adrenal medulla. Catecholamines include norepinephrine, epinephrine, and dopamine, which are involved in the modulation of the body’s cognitive and emotional state and other psychoactivities. Norepinephrine and dopamine levels decrease upon experiencing psychological stress. (Guo et al 2017)

Dietary sugar may play an important role in modifying the relationship between cortisol and visceral adipose tissue (VAT), such that cortisol is significantly associated with elevated VAT under conditions of high sugar intake. (Gyllenhammer et al 2014)

Thyroid – Adrenal Relationship

Cortisol hypersecretion can cause symptoms of a hypothyroid state, due to the feedback mechanisms involved, by reducing peripheral conversion of T4 to T3 and by inhibiting TSH stimulation of the thyroid. The problem arises when the feedback mechanism continues to act as if the patient is in a hypothyroid state due to this issue of peripheral conversion, while symptoms of a hypothyroid state continue even with a normalized TSH. In addition to hypothyroid symptomatology, the patient may experience bouts of female irregularity, lowered testosterone levels, and multiple muscle pains due to the conversion of pregnenolone into dehydroepiandrosterone (DHEA). Because DHEA is reduced into estrogens and testosterone, it has wide-ranging effects that could mask male- or female-specific conditions. (Wellwood & Rardin 2014)

When the adrenals have been weakened by chronic stress, emotional stress, trauma, or chemical stressors—such as food, the environment, and medications—this stress causes stimulation of cortisol and, over time, reduces TSH and T4 to T3 conversion and increases conversion to reverse T3. This effect causes the patient to feel even more fatigue and exhaustion. Treatment may be as simple as reducing the stress factors to reduce the disease progression. (Wellwood & Rardin 2014)

Hypothyroidism reduces [urinary] cortisol clearance, and the addition of thyroid hormone replacement increases [urinary] cortisol clearance. Additionally, hypothyroidism reduces the metabolic rate, thereby, reducing the need for cortisol. The increased metabolic rate accompanying thyroxine replacement increases the requirement for cortisol. Furthermore, a high serum concentration of TSH in the absence of primary thyroid failure can be a feature of adrenal insufficiency. (Upala et al 2016)

DHEA-S levels are influenced by several factors, most importantly age and gender, and several studies reported low DHEA-S levels in patients with documented hypopituitarism and hypothalamic-pituitary-adrenal (HPA) insufficiency. In particular, in patients with a newly diagnosed large pituitary tumor, DHEA-S levels appeared to be a reliable prognostic parameter for the diagnosis of HPA insufficiency. (Fischli et al 2008)

References
Bensky, Dan & Randall Barolet, Chinese Herbal Medicine Formulas & Strategies, Seattle: Eastland Press, 1990
Kaptchuk, Ted, J., O.M.D., The Web That Has No Weaver, Chicago: Congdon & Weed, 1983
Ma, Shou-Chun, MTCM, Chinese Nutrition Class Notes from Northwest Institute of Acupuncture and Oriental Medicine, Seattle, 1994
Maciocia, Giovanni, The Practice of Chinese Medicine, Edinburgh: Churchill Livingstone, 1994
Maciocia, Giovanni, The Foundations of Chinese Medicine, Edinburgh: Churchill Livingstone, 1989
Pitchford, Paul, Healing with Whole Foods, Berkeley: North Atlantic Books, 1993

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