Frequently asked questions (FAQs) about
SARDS and Adrenal Hormones
addressed by Caroline D. Levin RN
author of Living With Blind Dogs & Dogs, Diet, and Disease
Click here for additional SARD Resources
SARD dog recently had an ACTH test done. His cortisol levels were
normal, but he has all the symptoms of elevated cortisol—he’s
overweight, panting, and depressed. What’s going on?
adrenal glands become exhausted they increase production of adrenal
estrogen. This is an overwhelming pattern in SARD dogs. 90%-98% of dogs
tested have elevated estrogen and/or other sex-hormones — in other
words they have adrenal exhaustion.
estrogen is unrelated to ovarian estrogen and occurs in males, females,
altered and intact. Estrogen is molecularly very similar to cortisol
and is documented to cause many of the same symptoms: fatigue,
confusion, depression, seizures, incontinence, elevated liver enzymes,
A dog in adrenal exhaustion
can have a “normal” ACTH test because even though production of
cortisol is on the decline, the adrenal glands can still rise to the
challenge of a large stressor such as an injection of ACTH (ie. the
ACTH test). It would be like falling into bed at night after a long,
exhausting week at work. If you woke at 2am to find a bear in your
bedroom, you could still rise to the challenge and get out. The ACTH
injection is similarly the same type of stressor.
the dog appears to have the symptoms of excess cortisol along with a
normal ACTH test he may receive a diagnosis of atypical Cushing’s. This
is another phrase used to describe adrenal exhaustion and in these
cases it is really the rising levels of adrenal estrogen and other sex
hormones that produce these symptoms.
Returning sex-hormone levels to normal will resolve many/most of these symptoms. Treatment
includes cortisol and thyroid hormone replacement and minimizing
environmental factors that stimulate (and exhaust) the adrenal glands.
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Do all SARDS dogs develop adrenal exhaustion?
dogs react differently. Some percentage of SARD dogs clearly develop
adrenal exhaustion (elevated sex-hormones) based on their blood work
and clinical signs/symptoms. A small percentage of SARDS dogs go on to
develop true Cushing’s disease (a tumor on either the pituitary or
adrenal glands). The remaining portion of SARD dogs may tolerate
slightly elevated estrogen for a few years, giving the impression that
they have adapted.
suggests that SARD dogs have been producing high-normal or slightly
elevated levels of estrogen for some time before the onset of
blindness. Then a triggering factor increases estrogen production.
Examples include: springtime or autumn when adrenal activity normally
ramps up, a stressful event like home remodeling or kenneling, or
excessive vaccination. The tired adrenal glands are forced to secrete
even more estrogen. Consequently, dogs may start having accidents in
the house, an annual springtime ear infection, a seizure, or the onset
When the demand on the
adrenal gland wanes (springtime passes into summer, the dog returns
from the boarding kennel, or he recovers from the stimulus of a
vaccine) the estrogen level ay drop slightly to where some dogs can
tolerate it again. This is a time when owners feel the dog has
“adapted” and the problems are over. But “tolerate” does not mean
“thrive.” Prolonged exposure to estrogen causes silent damage to
internal organs such as the kidneys, liver, and brain. So testing for
adrenal exhaustion is beneficial for all SARD dogs.
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Is it important to treat a dog’s adrenal problems?
most definitely. Insufficient cortisol production (adrenal exhaustion)
and the resulting estrogen production can contribute to a poor quality
of life and gradual damage to the liver, kidney, and many other
internal organs and tissues. Prompt, aggressive treatment of adrenal exhaustion may play a role in sparing some retinal cells from destruction and restoring some functional vision.
adrenal exhaustion can drastically improve lethargy, confusion,
depression, immune system problems, etc. Many of the owners I talk to
say they “can handle the blindness” but wish they could just “have
their dog back,” meaning they just want to see his normal personality
return. Please see: Health Problems in an Untreated SARD Dog
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Why are replacement hormones given to SARD dogs every day instead of every-other-day like some other dogs get?
a healthy dog with working adrenal glands, daily doses of steroids
suppress natural cortisol production. This happens because the body
recognizes that prescription hormones are circulating in the
bloodstream and knows that the body doesn’t need any more from the
glands. So, dogs with working adrenal glands are given hormones every-other-day to prevent the glands from shutting off.
if a patient has adrenal exhaustion (the adrenal glands are too tired
to make sufficient cortisol) replacement hormones are required every
day. Adrenal activity is low so there is very little function left to
suppress anyway. The vast majority of SARD dogs fall into this category.
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vet told me there was a survey that said that SARD dogs don’t develop
additional medical problems. If this is true, how come my dog is so
I believe your veterinarian
is referring to a paper presented at the 2005 annual Veterinary
Ophthalmology meeting. The survey concluded that the majority of SARDS
dogs do not develop additional medical problems.
that paper, fifteen owners were surveyed 10-28 months after the SARDS
diagnosis. Of the 15 dogs, three had been euthanized or passed away
(all three were of advanced age), another one developed diabetes, and
one developed seizures. So depending on how you look at it 15% of the
dogs developed a serious medical problem or 33% developed a serious
medical problem and/or passed away. Either way, it’s a minority (less
However, there are two important things to consider about that survey
• How the dogs’ health status was evaluated
• The definition of a “medical problem”
to the summary, the survey asked owners two questions about the dogs’
health: whether they had symptoms of polyuria/polydipsia (excessive
urination and drinking) and whether any new medical problems had
appeared. From what I read, there were no diagnostic tests (lab work)
performed to assess the dogs’ health. It would have been very
interesting if body weight (obesity), liver function, or adrenal
hormones had been measured, or if the owners had been surveyed about
the variety of other symptoms SARDS dogs experience. Obesity itself is
considered a medical problem and it is reported to persist in most
untreated SARD dogs.
study presented two years earlier at the ACVO meeting, 9 of 10 SARD
dogs (90%) demonstrated abnormal levels of adrenal hormones. By
definition, abnormal hormone levels are also a medical problem.
Hormones such as adrenal estrogen are known to have gradual, long-term
effects including kidney and liver damage. Without blood tests, dog
owners would be unaware of such developments and would not report them
That said, it is
probably entirely true that only a minority (fewer than half) of SARD
dogs develop the more obvious health problems (severe depression,
seizures, autoimmune conditions, cancer, and liver disease, for
example) but if your dog is one of them, it’s a very real problem—I
know. The owners of these dogs tell me time and again how frustrating
it is to hear that their dog will have a “normal, healthy life” when
they can clearly see he’s suffering.
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Is the concept of adrenal exhaustion new? My vet had never heard of it before.
not sure why medical and veterinary schools don’t cover the stress
adaptation response more fully. Dr. Selye’s now-famous work has been
cited in thousands of research papers. He wrote 40 books and more than
1,700 articles on stress and related illness. So impressive have his
findings been that some authorities refer to him as "the Einstein of
Limited awareness could
be due, in part, to the fact that stress is basically a condition of
lifestyle. Nurses focus closely on the relationship between lifestyle
and health, so nursing schools focus on the stress response. Since my
background is in nursing, I applied these concepts to my work with SARD
dog owners. So, to answer that part of your question, the concept is
Many people resist the idea
that that physical irritation and lifestyle may play a role in SARDS.
It’s difficult for people to accept new information that conflicts with
what they already believe to be true. And some owners would rather not
know about potential problems that may happen in the future. These are
normal methods of coping.
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SARD dog of two years had her total estrogen level measured. It was
35.19. My vet said this is so close to normal that it’s nothing to
worry about but my dog is still lethargic and depressed. Can you tell
The lab you’re referring to has set the normal range for female total estrogen at 30.00-35.00 pg/mL. It is a very precise range. Blood levels even slightly above or below that normal range are meaningful.
some cases, doctors are not used to seeing such an exact range. It’s
been my experience, however, that SARD-dog owners report lethargy,
confusion, panting, excessive appetite and incontinence when total
estrogen seems “only slightly” elevated—in the range of 35.14 – 35.28
pg/mL. (These values refer specifically to female dogs, but a similar
pattern is noted in male dogs.) Hormone therapy to replace depleted
cortisol can be very helpful in such cases.
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How long does it take for hormone replacement therapy to start working? What will I notice in my dog?
varies among individuals. Improvement in mood and energy level are
often noted within 2-4 weeks. Other signs of elevated sex hormones,
such as obesity, heat intolerance, and coat changes, improve over 3-9
months. Remember, it took years of chronic irritation/physical stress
to reach the point of adrenal fatigue, and it takes some time to
reverse that situation.
that slows progress is poor GI absorption. If the intestinal tract is
inflamed (IgA levels are low) the dog will have difficulty absorbing
hormone pills and other medications. Improvement will be slow. Please
see the SARDS protocol (page 179, Dogs, Diet and Disease) for methods to deal with this.
levels of hormones normalize quickly, almost too quickly. The drastic
change may cause a short period of incontinence and confusion. This may
cause practitioners to question whether hormone replacement was
appropriate. However, as hormone levels equalize, these transitory
signs/symptoms resolve. A good analogy is dropping a rubber ball from a
great height. It bounces up and down several times (like the hormone
levels) until it comes to a resting state. Follow-up testing can
confirm that you are on the right track.
a dog has been subject to elevated estrogen levels for a long time,
some symptoms may persist even with treatment. The most common are the
food-seeking behaviors. I'm unclear as whether this is a learned
behavior or whether the appetite center in the brain has been
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When should a dog have adrenal estrogen/sex-hormone levels tested?
it was recommended that SARD dogs have an adrenal hormone panel run
once lifestyle changes had been implemented. More recently it’s become
clear that SARD dogs are already in adrenal fatigue within a week or
two of blindness. So it is beneficial to test and treat SARD dogs for
adrenal exhaustion at the time of diagnosis. An adrenal panel is
distinctly different than typical Cushing’s tests because it measures
adrenal estrogen. If estrogen levels are high, it is suggestive of
adrenal exhaustion. Prompt treatment not only addresses the underlying
adrenal problem but also restores some vision in more than 20% of cases.
other than SARD dogs can suffer from adrenal exhaustion, too. Dogs that
will benefit from adrenal testing and treatment include those with:
Poorly-controlled diabetes or pancreatitis (Elevated estrogen raises
blood glucose, cholesterol, triglyceride, and lipase levels.)
- Poorly-controlled epilepsy (Elevated estrogen reduces the seizure threshold and increases nerve cell transmissions.)
inflammatory bowel disease or allergies (Elevated estrogen suppresses
immunoglobulin levels and increases histamine release, causing red,
itchy, inflamed tissues and GI distress.)
Cushing’s disease or those dogs suffering from signs/symptoms of
Cushing’s disease but with normal results on standard Cushing’s tests
(Estrogen causes many effects similar to cortisol.)
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What is the current working theory for the cause of SARDS?
thesis is that SARDS is first and foremost an adrenal problem that
stems from the "modern-day lifestyle,” that is — commercial pet food,
annual vaccination, and chronic pesticide exposure — three modern-day
elements that are physically irritating. Afterall, SARDS has only been
diagnosed since the late 1970s.
these three, I suspect diet is probably the biggest piece because it's
something we do to the dogs twice a day every day. I do not believe it
is any one thing in pet food, or any one type of vaccine, or a single
chemical. They all irritate the body. Chronic irritation increases
adrenal gland activity and the hormones that are produced there. (See: SARDS, diet, and lifestyle study.)
addition, there certainly must be an indirect genetic tendency to the
problem, otherwise every dog in the America, and certainly every dog at
the local dog pound would have SARDS. And even though SARDS affects
many breeds, it was first reported in Dachshunds and Miniature
Schnauzers at higher rates. I'm aware of other incidences that suggest
a vague genetic link, for example: a female Golden Retriever was
diagnosed with SARDS and the pup she had two years earlier developed
autoimmune Addison's disease (destruction of the adrenal gland); and
one breeder of Australian Terriers actually reported SARDS in both a
stud dog and his daughter.
the predisposition involves a flaw in the retinal cells, an
over-activity of the adrenal gland (the body overreacts to even small
stressors) or a predisposition to low Immmunulogobulin A / an irritated
intestine is unclear. (See: Dietary changes in a SARD dog.)
this author is investigating methods of protecting retinal cells from
damage early in the course of the disease. This approach, along with
restoring normal adrenal function, has been shown to spare some retinal cells in about 20%-25% of cases.
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weeks before my dog developed SARDS she was taken to the vet’s for her
annual blood work, vaccinations, etc. and everything was fine. Three
weeks later, WHAM, she was blind. Is there any connection to the
vaccines she received?
It seems that
dogs tested close the time of vision loss are already in adrenal
fatigue, producing excess estrogen. (Readers please see: Overview of adrenal fatigue and Journey with a SARDS dog
for discussions of adrenal fatigue.) Some of these individuals wear out
their adrenal glands gradually over a very long time. Owners report
that their dog had growing problems with allergies, GI problems, liver
disease, head tics, panting, obesity, etc.
individuals seem to reach the critical hormone levels after a spike in
adrenal activity such as you're describing: some proverbial straw that
breaks the camel's back. These include vaccine incidents, intense
psychological stressors (spending a week at a boarding kennel, home
remodeling, etc.), pesticide application, or the arrival of spring
(when adrenal activity normally increases). Below is a simple graphic.
Dog #1 (dark line) has no identifiable trigger but gradually increases
estrogen levels until they reach a critical level. Dog #2 has an
identifiable trigger and a spike in adrenal estrogen activity just
prior to SARDS onset. Of course it’s possible that all SARD dogs have a
trigger and owners are just unaware of them. In either case, estrogen
levels have likely crossed a critical threshold and damage the retina.
Elevated estrogen is a known excitotoxin that damages nerve/retinal
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dog had her adrenal hormones tested and both cortisol and estrogen were
above normal. My vet expected it to be one OR the other, not both. What
A small minority of SARD dogs produce both elevated adrenal estrogen and what appears to be
elevated cortisol levels. This scenario warrants a closer look because
these two things (elevated estrogen and elevated cortisol) do not occur
at the same time. The current literature indicates one primary reason
for adrenal estrogen to rise and that is due to insufficient
cortisol production. So, if estrogen production were elevated, one
would not expect to see simultaneously elevations in coritsol.
explanation for this high cortisol/high estrogen scenario entails
something called an isomer— a mirror-image molecule— of cortisol. (A
good analogy for an isomer is to simply look at your hands: each has
five fingers but the thumb is on the opposite side—a mirror image.)
Under chronic stress, some individuals increase production of a hormone
isomers and in this case it’s called "11-epi-cortisol.” This occurs
when the body is trying hard (but failing) to make real cortisol.
Isomer levels increase instead.
laboratory tests currently available in medical/veterinary practice
cannot differentiate between cortisol and 11-epi-cortisol. (Only a few
limited research facilities can distinguish between them.)
Consequently, 11-epi-cortisol levels also show up as “cortisol” on most
Unfortunately, these isomer molecules are not useable by the body. They are inactive. The body still feels the effects of low
cortisol even though the laboratory test may read high cortisol.
Therefore, adrenal estrogen becomes the primary marker when evaluating
and monitoring SARD-affected dogs. When adrenal estrogen is elevated,
holistic veterinarians will still supplement glucocorticoids, even if
the cortisol level is “high”, too. (See: Case Report #5) With this treatment both cortisol and estrogen
levels return toward the normal range. Glucocorticoid replacement
reduces chronic ACTH simulation, which in turn normalizes adrenal
estrogen and 11-epi-cortisol production.
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Can a dog with SARDS have any vision if the ERG is flatline?
Yes. There have been several reports from veterinary ophthalmologists and general practice veterinarians. (See Case Report 2 or Daisy’s case.) Researchers at Iowa State University report similar findings.
flatline ERG indicates a lack of retinal activity. It does not always
mean the retina is irreversibly “destroyed”. One explanation for a
temporary lack of ERG response involves a condition called
“hyperpolarization” — a big word that means the retinal cells are
over-stimulated and can’t relax — rather like having a charley-horse in
your calf muscle. In the retina, hyperpolarized cells are temporarily
unable to send visual information to the brain.
retina becomes hyperpolarized when excessive calcium enters the cells—a
process that occurs when estrogen levels are high. This is another
reason it’s important to address underlying adrenal dysfunction in
SARD-dogs. When the adrenal exhaustion is treated, it may be possible
to spare some cells from destruction.
on, if retinal cells finally depolarize and some have been spared, a
dog may demonstrate some functional vision even when the ERG is
flatline. Veterinary ophthalmologists suspect that this limited vision
is just insufficient to register on the ERG.
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Is SARD an autoimmune or immune-mediated disease—and what’s the difference?
“immune-mediated” is a blanket term that covers three types of disease:
1) an allergic response that stems from some type of infection 2)
antibodies that attack the patient’s own body—an autoimmune reaction—
or 3) antibodies that develop on surface tissue in response to an
outside irritant, such as “Farmer’s lung’.
past research done on SARDS, we know several things. To date, no
bacterial, viral or protozoal infection has been associated with SARDS
cases. This would suggest that SARD is not an infection-induced
allergic response (item 1, above). In 2006, two independent studies
found no autoimmune antibody activity specific to SARDS dogs.(1,2)
This would suggest that SARDS is not an autoimmune disease. Finally,
the retina, located in a virtually closed system, is not in contact
with outside irritants, which rules out item 3 as a cause. By these
criteria SARDS doesn’t qualify as an immune-mediated disease.
Consequently, I suspect there may be some controversy in the veterinary
community when SARDS is compared to immune-mediated retinopathy in
Why then, would
immunoglobulin injections help some SARDS dogs? Well, research also
tells us that immunoglobulins influence a vast number of functions in
the body and one of those is to regulate how much calcium enters
certain cells. When estrogen levels are elevated, excess calcium flows
into nerve and retinal cells. Excess calcium damages the tiny organs
inside the cells and the body eventually destroys these cells. Excess
estrogen also suppresses immunoglobulin levels (see: retrospective study).
So, by restoring normal immunoglobulin levels it may be possible to
reduce calcium overload in retinal cells. This in turn, would reduce
the resulting cellular damage.
Gilmour MA et al. Evaluation of a comparative pathogenesis between
cancer-associated retinopathy in humans and sudden acquired retinal
degeneration syndrome in dogs via diagnostic imaging and western blot
analysis. American Journal of Veterinary Research 2006;67:877-881
Keller RL et al. Evaluation of canine serum for the presence of
antiretinal autoantibodies in sudden acquired retinal degeneration
syndrome. Veterinary Ophthalmology 2006;9:195-200.
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Copyright © Caroline D. Levin RN. September 18, 2006. All rights reserved. www.petcarebooks.com