All About Adrenals

Dr Chinnadorai Rajeswaran, consultant endocrinologist explains about adrenal problems and its endocrine management. Please email him, if you need more information.

The adrenal glands are a pair of triangular glands that sit on top of the kidneys. They are responsible for the release of several hormones that regulate metabolism, immune system function, and salt-water balance. They also help in the body’s response to stress.

Adrenal disease occurs when excessive hormones are produced and too little is produced.

Common adrenal gland problems include:

There are several reasons why the adrenal gland malfunctions.

Problems in the adrenal gland could be due to:

  • Tumour
  • Infection
  • Injury
  • Auto immune conditions
  • Bleeding
  • Lack of blood supply.

Adrenal gland closely works with the pituitary gland.

Adrenal disease can lead to serious complications and can dramatically affect quality of life.

People with problems with adrenal gland can present with a variety of symptoms including:

  • Tiredness
  • Loss of weight
  • Headache
  • Excessive sweating
  • Weight Loss
  • Weight gain
  • Dizziness
  • Recurrent collapse
  • Low blood pressure
  • High blood pressure
  • Increased hair growth (Hirsutism)
  • Infertility
  • Irregular periods and many more.

Some of adrenal diseases can be life threatening. It is therefore extremely important that appropriate investigations are done by an endocrinologist and treatment initiated soon.

Cushing’s syndrome

Cushing’s syndrome is a condition which occurs when the body is exposed to high level of glucocorticoid (steroid) also commonly called cortisol for a long period. Increased steroid levels in the body may occur due to several reasons, including:

  • Steroid intake (injections, medications, inhalers etc)
  • Steroids produced by adrenal disease
  • Steroids produced by ACTH (Adrenocorticotrophic hormone) secreting tumour of the pituitary gland (Cushing’s Disease)
  • Steroids produced by ACTH other than pituitary gland

Excess steroids can lead to either or all of these features:

  • Fatty hump between your shoulders (buffalo hump)
  • A rounded or moon face
  • Pink/ purple stretch marks on skin

What are the signs and symptoms of Cushing’s syndrome?

 In addition to the above features mentioned, people who develop Cushing’s can have several symptoms and signs. These depend on the level of excess cortisol in the body and how long they have been around in the body. There is a condition called “cyclical Cushing’s”, where in the symptoms and signs of Cushing’s comes and goes and can be difficult to diagnose.

Some of the common and rare presentations are mentioned below:

  • Weight gain, typically involving midsection, upper back and face.
  • Easy bruising due to fragile skin
  • Acne
  • Hirsutism
  • Menstrual periods abnormalities
  • Low libido
  • Infertility
  • Erectile dysfunction
  • Easy fatigability
  • Depression and anxiety
  • Hypertension
  • Osteoporosis

How is Cushing’s syndrome diagnosed?

 Investigation is done to confirm a diagnosis of Cushing’s syndrome or Cushing’s disease. Thereafter test is done to identify the exact location in the body, which is causing Cushing’s.

 This involves several blood tests and urine tests. Once baseline blood tests are done, further investigations include overnight dexamethasone suppression test and low and high dose dexamethasone suppressions test. Scans of the Pituitary, adrenal or other parts of the body if appropriate may also be requested.

Investigations is usually done to check if complications of Cushing’s syndrome are present. This includes tests to rule out diabetes, osteoporosis and other conditions which could result from Cushing’s.

 How is Cushing’s syndrome treated?

 Treatment of Cushing’s syndrome will depend on the source of excess cortisol production. Surgery may be undertaken to remove the tumour. If surgery does not help to remove the tumour radiotherapy may be considered. Sometimes radiotherapy alone may be the choice of treatment.

Medications to control cortisol production may be used before surgery or if surgery and radiotherapy is not considered.

Treatment will also be directed towards complications of Cushing’s syndrome.

In some people the tumour causing Cushing’s can affect other hormones, which will need to be addressed.

What can happen if Cushing’s syndrome or disease is not treated?

 If Cushing syndrome is not promptly diagnosed and treated, several complications is known to occur, which include:

  • Osteoporosis, which can result in bone fractures.
  • Hypertension (High blood pressure)
  • Type 2 diabetes and its related complications
  • Frequent infections
  • Loss of muscle mass (Sarcopenia) and strength

Please see an endocrinologist near you if you are concerned or suspect Cushing’s syndrome

Addison’s Disease

Adrenal insufficiency is a condition in which the adrenal glands do not produce adequate hormones like cortisol and aldosterone. Commonest form of adrenal insufficiency is Addison’s disease, also called primary adrenal insufficiency. If Addison’s disease is not identified and treated, adrenal crisis may occur, which is a life threatening condition.
Addison’s disease in most people is due to an autoimmune condition, however it may also result from infection, tumour or injury. In some people secondary adrenal insufficiency may occur, when their pituitary gland does not produce adequate hormone called ACTH (Adreno Cortico Trophic Hormone). ACTH produced by pituitary gland stimulates the adrenal gland to produce cortisol.

What are symptoms of adrenal insufficiency (Addison’s disease)

  • Weakness and Fatigue
  • Weight loss
  • Reduced appetite
  • Nausea and Vomiting
  • Abdominal pain
  • Altered bowels
  • Darkening of the skin/scars
  • Dizziness  more so on standing

If the above symptoms are not treated promptly, adrenal crisis may result with a drop in blood pressure and can be life threatening.

Diagnosis and Treatment

Your endocrinologist will arrange a number of blood tests and scans to ascertain if the problem is in the adrenal gland or pituitary gland. Also investigations will be arranged to find the underlying cause.

Treatment of Adrenal insufficiency (Addison’s disease) is replacement of deficient steroids.

Patients who should have asteroid emergency injection kit include:

  1. Addison’s disease
  2. Congenital adrenal hyperplasia
  3. Both adrenal removed (Bilateral adrenalectomy)
  4. Hypothalamus problem requiring steroids
  5. Pituitary problems requiring steroids
  6. Those advised to take steroids for intercurrent illness

Patients in whom new steroid emergency steroid NHS card/Medic alert bracelet should be carried include:

  1. Addison’s disease
  2. Congenital adrenal hyperplasia
  3. Both adrenal removed (Bilateral adrenalectomy)
  4. Hypothalamus problem requiring steroids
  5. Pituitary problems requiring steroids
  6. On prednisone 5mg/day or more
  7. Dexamethasone 0.5mg/day or more
  8. Hydrocortisone 15mg/day or more
  9. Inhaled steroids like Fluticasone >500mcg/day;Beclomethasone>1000mcg/day;Nasal steroids>1000mcg/day
  10. Drugs which inhibit cortisol clearance like itracanazole, anti retro viral drugs

A phaeochromocytoma (fee-o-kro-mo-sy-to-ma) is a rare, usually benign tumour that develops in an adrenal gland.

Phaeochromocytoma

Phaeochromocytoma releases hormones that may cause high blood pressure, headache, sweating and palpitations. People with this tumour may complain of symptoms of a panic attack. Symptoms occur due to the release of hormones like adrenaline, noradrenaline and dopamine. It is known that these hormones are released at random, so the symptoms can vary and there is no pattern to how people get affected. If pheochromocytoma is not diagnosed and treated, it can be life threatening and serious complications are seen.

What are the symptoms and presentation of Phaeochromocytoma?

Symptoms vary and as explained above these symptoms can occur at random intervals. Common symptoms of phaeochromocytoma include:

  • High blood pressure (hypertension)
  • Headache
  • excessive sweating
  • Palpitations
  • Panic attacks
  • Shortness of breath
  • Anxiety

Certain conditions, activity or food can make these symptoms worse.

  • Physical exertion
  • anxiety
  • Anaesthesia
  • Surgery

Certain food like chocolates, cheese, wine, some beers and smoked meat can worsen symptoms.

How is phaeochromocytoma diagnosed and treated?

Your endocrinologist will arrange a series of blood and 24 hour urine test followed by scans and may also include specialised scans.

Genetic testing may also be conducted to check for any associated conditions. Family members may also be checked to see if it is genetically transmitted and ensure no one else is suffering from this condition.

There are several tumours which may co-exist in people with phaeochromocytoma, which include: neurofibromatosis and hereditary paraganglioma. Phaeochromocytoma in rare instances may be part of a condition called Multiple Endocrine Neoplasia (MEN) type 2.

Treatment involves medications to lower blood pressure and thereafter surgery is considered to remove the tumour. Sometimes hormones may be produced in areas other than the adrenal gland, which needs investigating.

What happens when Phaeochromocytoma is not treated?

When phaeochromocytoma is not identified and treated promptly, high blood pressure can damage the heart, brain and kidneys resulting in heart failure, stroke, kidney failure and damage to the back of the eye (Retinopathy). If you have uncontrolled blood pressure and/or have symptoms like headache, excessive sweating and palpitation, you should consult an endocrinologist near you.

Conn’s syndrome

Conn’s Syndrome (Primary hyperaldosteronism) is a condition where the adrenal gland produces too much of an hormone called aldosterone. Aldosterone is the hormone which controls sodium and potassium salts in the body and also balances the water content and blood pressure. Conn’s syndrome was thought to be rare but it is now known to occur in as many as 5-15% of people with high blood pressure (Hypertension).

Most common cause is due to benign tumours of one or both the adrenal glands. Rarely cancerous lesion of adrenal can also produce excess amount of aldosterone. Some type of Aldosteronism or excess aldosterone production by adrenal gland is also known to run in families.

What are the symptoms to Conn’s syndrome?

Symptoms of Conn’s syndrome can be subtle. Conn’s syndrome is usually suspected when some one has high blood pressure and an underlying cause is being investigated. Common symptoms of Conn’s syndrome include:

  • Generalised weakness

  • Muscle cramps

  • Excessive thirst

  • Frequent urination

  • Bloated abdomen

  • Weak bowel movements/Abdominal pain due to low potassium

  • High blood pressure which may lead to heart failure, stroke, kidney failure and changes in the retina.

How is Conn’s syndrome diagnosed?

Your endocrinologist will arrange a number of blood tests to check for salts and hormones in the body. This is followed by scans to confirm the diagnosis.

How is Conn’s syndrome  treated?

Treatment involve medications like spironolactone which not only corrects potassium levels but also controls hypertension. It is important that blood pressure is controlled. Some patients will also be offered surgery of the adrenal gland

If the aldosterone is coming from a tumour in one adrenal gland they can potentially be cured by removal of the adrenal gland tumour.

What can happen if Conn’s syndrome is not treated?

If Conn’s syndrome is not treated appropriately, low potassium can lead to increasing weakness and some people may have irregular heart rhythm.

High blood pressure due to Conn’s syndrome if not corrected can lead to stroke, heart attack, kidney failure and atrial fibrillation or AF.

 

Dr Chinnadorai Rajeswaran is a consultant Physician specialising in Endocrinology, Diabetes and Obesity. As a private endocrinologist he has private endocrine, diabetes and weight loss clinics in Harley Street, London, Claremont Hospital, Sheffield, Nuffield Hospital, Leeds and simplyweight, Bradford.

He has face to face consultations with people from Leeds, Sheffield, Barnsley, Rotherham, Chesterfield, Doncaster, Wakefield, Huddersfield, Bradford, Harrogate, Leeds, Sheffield and London. He also offers video consultations.

 

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