hello everyone,
I made a post two days ago about my cortisol am levels. I wanted to ask your opinion on the fact that my Dr wants me to get an ACTH stimulation test done. I’m not sure if this is necessary? Since my levels are within range
Levels 207 reference range 101-535
In a healthy person the output of cortisol throughout the day and night is not constant. It follows a common pattern which shows as a high output of cortisol at around the time people wake up each day then the amount slowly drops throughout the day. At night the amount of cortisol stays low for a few hours then it rises quickly when waking up time approaches.
See the graph on this link (the black line) :
clemandthyme.com/2023/03/03...
The ACTH Stimulation Test is more commonly known in the UK (and on this forum) as the Short Synacthen Test (SST).
If you want to see other posts on this test you should search the forum for "synacthen" (but sadly the search function on this website/forum is very poor).
en.wikipedia.org/wiki/ACTH_...
The adrenal glands produce cortisol. The test you've already had measured the cortisol produced by your adrenal glands. I hope it was tested at about 8am - 9am - the test is supposed to capture your peak cortisol output. What time was your blood draw in relation to your normal waking up time?
But the adrenal glands don't just produce cortisol when they feel like it. They are stimulated to produce cortisol by ACTH which is produced by the pituitary gland.
en.wikipedia.org/wiki/Adren...
So even if your adrenal glands are healthy your output of cortisol could still be low because your pituitary is not producing sufficient ACTH.
So the ACTH Stimulation Test should involve ...
1) Blood test before the ACTH Stimulation test is begun to measure your own production of ACTH and your own production of cortisol.
2) Then you get injected with an artificial form of ACTH (probably tetracosactide). This is intended to stimulate your adrenal glands to produce more cortisol. Blood samples are taken after 30 minutes then 60 minutes to see how well your adrenal glands are reacting to the extra ACTH and how much cortisol is being produced.
3) If your cortisol stays low even after the ACTH is injected then your adrenal glands are not capable of producing enough cortisol for your needs.
4) If your cortisol is low at the start of the test (step 1 above) but rises well after the ACTH is injected then your adrenal glands are capable of producing cortisol and are healthy, but your pituitary gland is not able to produce enough ACTH for your needs and your pituitary is not working as it should.
...
Your output of cortisol was rather low (in my not-a-doctor opinion), and the ACTH Stimulation Test aka Short Synacthen Test is worth doing to get more information on why you aren't producing adequate cortisol.
You might find this link helpful - see pages 68 - 70 :
imperialendo.co.uk/Bible202...
But there is a possibility it isn't available outside the UK. According to that "Endocrine Bible" link the preparation required before the test is :
PREPARATION
• If on hydrocortisone the final dose of hydrocortisone should be at midday, on the day prior to the
test. If on prednisolone, the dose in the morning of the test should be delayed till after the test, so
no dose needs to be omitted before the test.
• HRT or any oestrogen should be discontinued for 6 weeks before the test.
• In patients in whom the test is being used to screen for 21-hydroxylase deficiency, the test should
be done in the follicular phase because progesterone levels rise substantially in the luteal phase,
and there is some cross reaction between the 17-OHP assay and the Progesterone assay.
• Admission is required if there is a risk of Addisonian crisis (rare).
• 18-20g cannula.
• Saline flush.
• 10ml syringes x 4.
• 3 red or yellow top Vacutainers for cortisol (same samples for 17-OH progesterone)
• 1 EDTA tube (purple top Vacutainer) for ACTH basal sample + ice.
• 1 ampoule of 250 micrograms tetracosactrin (Synacthen).
Reembow Do the test, but request that they also do an ACTH blood test immediately before the SST (ACTH stim test) to check your body’s own ACTH level.
Ok @jumpjiving thank you for the insight. I really appreciate it
Reembow,
Your cortisol level is low. Having an ACTH stim test will allow you to more easily identify why this is so (ACTH should elevate cortisol levels).
However, as JumpJiving says it is important to get ACTH blood levels tested before the stim test to ensure levels are 'normally' adequate.
These steps allow you to see if you have primary or secondary adrenal problems.
So yes I will take your advice and ask for that. But I also want to say i did an ACTH almost a year ago ( they forgot to test for the cortisol am at the time 😵💫 ) and it was 3.37 pmol/l reference range 1.03 - 10.73
Reembow It will want to be repeated - the ACTH wants to be done immediately prior to the SST in order to interpret the results with a high degree of confidence
Ok great 👍🏻 thank you so much
Reembow,
ACTH looks low also and theoretically should be higher whilst trying to encourage further from an insufficient cortisol production, but we shouldn't speculate at this stage as a lot can happen in a year. Good luck with your stim test, and remember many of us hypos with previous adrenal issues have made full recovery when thyroid hormone inadequacies have been addressed.
also JumpJiving would this ACTH have been considered low ?
Reembow It's within range, but ACTH levels vary through the day, so depends when the blood was drawn. Most of the time, for suspected adrenal insufficiency, the thing that people look for is high vs. non-high, rather than high vs. low. Your previous test was non-high.
When early morning cortisol is low, high levels of ACTH suggest primary adrenal insufficiency, non-high (or low) levels of ACTH suggest secondary or tertiary adrenal insufficiency.
Similarly, when early morning cortisol is low, an inadequate cortisol response to the SST suggests that the adrenals are not working, usually because of primary adrenal insufficiency or because the adrenals have atrophied, whereas an adequate cortisol response to the SST suggests secondary or tertiary adrenal insufficiency, but without the adrenals having yet atrophied.
In combination, an ACTH test and a SST combined, give a pretty good indication of primary vs non-primary, but don't distinguish between secondary and tertiary. To distinguish between secondary and tertiary, a CRH test (which also goes by other names - it's another type of stim test) may be done, and possibly a pituitary scan. There is another test that can be done after that, but it has some risks associated, so not the first thing people go for.
Thank you for the response JumpJiving so this test will not give me a yes or no answer? rather the low cortisol is confirmation already ? The ACTH test will just say why ? Does this mean that I am already confirmed for some kid if adrenal fatigue ?
Reembow The diagnostic process involves a number of steps, each of which increases confidence in the diagnosis. Occasionally, it will be possible to say "100% you have adrenal insufficiency with a specific cause", but most often it will be 99% even after the basic tests.
As a layperson, given your early morning cortisol blood test level, (as long as the tests were done without influence of medications, supplements etc) I would suspect that you will be given a diagnosis of adrenal insufficiency. Once the result of your SST is back (adequate cortisol response vs. inadequate cortisol response - any endo that says normal or fine is being lazy IMHO), particularly if with a new ACTH result as well, it should be pretty clear whether that is primary or non-primary.
In terms of terminology (which even endo's get wrong in places):
Adrenal insufficiency is the UK umbrella term of primary, secondary and tertiary problems causing low cortisol. Hence primary adrenal insufficiency, secondary adrenal insufficiency and tertiary adrenal insufficiency.
Primary adrenal insufficiency is caused by an issue with the adrenal glands themselves. There are various causes. The most common in the western world is auto-immune. The most common worldwide is TB. But there are other causes.
Addison's Disease is another name of primary adrenal insufficiency.
Secondary adrenal insufficiency is caused by an issue with the pituitary glands.
Tertiary adrenal insufficiency is caused by suppression of the HPA axis, typically by steroid or opioid use. Many doctors incorrectly lump tertiary in under the secondary banner.
Adrenal insufficiency can be referred to as hypocortisolism, adrenocorticol insufficiency, or various other names. Whichever of these names is used, it is a recognised medical condition.
Do not confuse adrenal insufficiency with adrenal fatigue. You won't find NICE guidelines about adrenal fatigue, or NHS pages about adrenal fatigue. If you look at patient.info/hormones/adren... you will find this:
"Adrenal fatigue is a theory that the adrenal glands can become 'overworked' from chronic stress, leading to symptoms such as fatigue and low energy.
However, there is no scientific evidence to support this claim. Adrenal fatigue is not recognised as a medical condition by professional medical societies, and the consensus amongst mainstream doctors is that it does not exist as a disease."
I won't be debating the existence of adrenal fatigue with anybody - the view of the medical and scientific community is very clear.
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