Adrenal Dysfunction (Adrenal Gland Disorders)

What the adrenal glands do

Each adrenal gland has two parts:

Cortisol output is controlled by ACTH from the pituitary gland in the brain. Aldosterone is controlled mainly by the kidneys' renin system and potassium levels.

Adrenal insufficiency (too little hormone)

Primary: Addison's disease

The adrenal glands themselves are damaged, most often by autoimmune attack, less often by tuberculosis, infections, bleeding or cancer spread. Both cortisol and aldosterone are low. See Addison's disease.

Secondary and tertiary

The pituitary does not make enough ACTH (tumors, surgery, radiation, injury) or, most commonly, long-term steroid medicines (prednisone, inhaled or injected steroids at high doses) have suppressed the body's own production. Stopping steroids suddenly can trigger insufficiency. Aldosterone is usually normal.

Symptoms of adrenal insufficiency

• persistent fatigue and weakness
• weight loss and poor appetite
• nausea, vomiting and abdominal pain
• dizziness on standing and low blood pressure
• salt craving
• darkening of the skin, gums and skin creases (primary only), see hyperpigmentation
• low sodium, high potassium and low blood sugar on tests

Adrenal crisis

A life-threatening emergency triggered by illness, injury, surgery or missed doses in someone with adrenal insufficiency: severe vomiting, abdominal pain, confusion and shock. It needs immediate injected hydrocortisone and IV fluids. See adrenal crisis.

Adrenal overproduction

Cushing syndrome (too much cortisol)

Most often caused by taking steroid medicines. Other causes are a pituitary tumor (Cushing's disease), an adrenal tumor or, rarely, other tumors making ACTH. Features include weight gain in the face, neck and belly, purple stretch marks, thin skin and bruising, muscle weakness, high blood pressure, diabetes, mood changes and bone thinning. See Cushing syndrome.

Primary aldosteronism (too much aldosterone)

An adrenal adenoma or overactivity of both glands causes high blood pressure, often hard to control, sometimes with low potassium causing cramps and weakness. It is underdiagnosed and is found in a significant minority of people with resistant hypertension. See hyperaldosteronism.

Pheochromocytoma (too much adrenaline)

A rare tumor of the adrenal medulla that causes episodes of pounding headache, sweating, palpitations, anxiety and very high blood pressure. Some are inherited. See pheochromocytoma.

Congenital adrenal hyperplasia

An inherited enzyme deficiency that reduces cortisol and increases androgens. Severe forms appear in newborns with salt-wasting crises or ambiguous genitalia; milder forms cause early puberty, hirsutism and irregular periods. See congenital adrenal hyperplasia.

Adrenal incidentalomas and cancer

Adrenal lumps found by chance on scans are common, especially with age. Most are harmless, non-functioning adrenal adenomas, but all should be checked for hormone production and features of cancer. Adrenal cancer is rare.

Diagnosis

Testing depends on the suspected problem:

• Insufficiency: early-morning cortisol and ACTH; an ACTH (cosyntropin) stimulation test, which checks whether cortisol rises after an injection; sodium and potassium; renin and aldosterone.
• Cushing syndrome: late-night saliva cortisol, 24-hour urine cortisol, or an overnight dexamethasone suppression test, then tests to locate the source.
• Primary aldosteronism: aldosterone-to-renin ratio, confirmatory tests, then CT and sometimes adrenal vein sampling to decide on surgery.
• Pheochromocytoma: plasma or urine metanephrines.
• Imaging: CT or MRI of the adrenal glands; pituitary MRI for ACTH-dependent conditions.

Treatment

• Adrenal insufficiency: lifelong hydrocortisone (or similar) tablets, plus fludrocortisone in Addison's disease to replace aldosterone. Sick day rules (doubling doses during fever or illness), an emergency injection kit and a medical alert ID are essential.
• Cushing syndrome: reducing steroid medicines gradually if they are the cause; surgery to remove a pituitary or adrenal tumor; medicines that block cortisol production.
• Primary aldosteronism: keyhole removal of a single overactive adrenal gland, or mineralocorticoid receptor blockers such as spironolactone when both glands are involved.
• Pheochromocytoma: alpha-blocker medicines, then surgical removal; genetic testing for the person and family.
• Congenital adrenal hyperplasia: steroid replacement and specialist care.

Outlook

People with adrenal insufficiency who take replacement correctly and follow sick day rules can live normal, active lives. Surgery often cures primary aldosteronism, adrenal Cushing syndrome and pheochromocytoma. Ongoing endocrine follow-up is important for all adrenal disorders.

Frequently asked questions

What are the symptoms of adrenal dysfunction?

It depends on the hormone involved. Low cortisol and aldosterone cause fatigue, weight loss, dizziness, salt craving and skin darkening. Too much cortisol causes weight gain, stretch marks and high blood pressure. Too much aldosterone causes high blood pressure and low potassium. Too much adrenaline causes episodes of palpitations, sweating and headache.

Is adrenal fatigue a real condition?

No. Adrenal fatigue is not a recognized medical diagnosis, and there is no evidence that ordinary stress wears out the adrenal glands. Fatigue is real, but it has many causes worth testing for, including true adrenal insufficiency, thyroid disease, anemia, sleep disorders and depression.

What are adrenal problems in women?

Women can have any adrenal disorder. Some are more common or show differently in women: autoimmune Addison's disease and Cushing syndrome are more common, and excess adrenal androgens, as in congenital adrenal hyperplasia or adrenal tumors, cause hirsutism, acne and irregular periods.

How is adrenal insufficiency diagnosed?

Doctors measure cortisol early in the morning and then usually perform an ACTH stimulation test, which shows whether the adrenal glands can increase cortisol after an injection. ACTH, sodium, potassium, renin and aldosterone levels help distinguish primary from secondary causes.

Can you live a normal life with adrenal insufficiency?

Yes. With daily hormone replacement, extra doses during illness, an emergency injection kit and a medical alert ID, most people live full, active lives. The key risk is adrenal crisis, which can be prevented by never missing doses and acting early during illness.