Details of Adrenal Insufficiency

People who have adrenal insufficiency have many of the same symptoms as those who have hypothyroidism. They're tired, depressed, and weak. They may have joint and muscle pain and may sleep poorly. They may also have dry skin. The difference is patients with adrenal insufficiency tend to lose weight and get dehydrated, while hypothyroid patients gain weight and retain fluids.

In addition, people with adrenal insufficiency may have trouble recuperating from colds and illnesses, and have low blood pressure and low blood sugar. They're frequently dizzy when they stand up, and may have nausea, vomiting, and diarrhea. After a while, they may lose weight and notice a darkening of their skin. They may also develop cravings for salty food. In people who have hypothyroidism as well, these symptoms worsen once they start taking thyroid hormone replacement.

Alert

People with an aldosterone deficiency should avoid low-salt diets. In fact, some need to be on a high-salt diet. Low aldosterone causes the kidneys to excrete excess salt, which lowers blood volume. The reduction in blood volume is especially hard on the brain. Without enough blood reaching the brain, patients are often fatigued and may experience a drop in blood pressure when they stand up.

Causes

It's rare for the adrenal glands to go haywire. When they do, it can sometimes be a problem with the glands themselves, which can reduce both the amount of cortisol and aldosterone. In some cases, an adrenal problem is actually a problem with the pituitary gland, which reduces the amount of ACTH the pituitary releases and hampers the production of cortisol. Several diseases and events can cause adrenal insufficiency, including:

  • Addison's disease (primary adrenal insufficiency), which is most often caused by an autoimmune attack on the adrenals

  • Congenital adrenal hyperplasia, an inherited disorder characterized by a deficiency in cortisol and, in some cases, aldosterone. The condition occurs because an enzyme that produces cortisol is not working properly, and therefore the synthesis of cortisol is blocked

  • Surgical removal of the adrenal glands

  • Surgical removal of the pituitary gland

In some cases, adrenal insufficiency is a temporary medical problem brought on by infection or surgery to remove a tumor from the pituitary gland or adrenal glands. Treatments to reduce elevated cortisol levels found in Cushing's syndrome can also trigger a temporary bout of adrenal insufficiency.

Diagnosis and Treatment

Making a diagnosis for adrenal insufficiency isn't always easy. The symptoms often develop gradually and sometimes are not serious enough for the patient to seek treatment. In about 25 percent of cases, it isn't until the patient develops acute adrenal insufficiency that treatment is sought. When adrenal crisis — sometimes called Addisonian crisis — occurs, symptoms are much more severe and may include abdominal pain, severe vomiting and diarrhea, dehydration, low blood pressure, and loss of consciousness. Without immediate treatment, an adrenal crisis can be fatal.

Fortunately, most people do get medical help before a crisis occurs and will report their symptoms to their doctors. To determine if you have a problem, your doctor needs to measure the amount of ACTH coming from the pituitary and the amount of cortisol being produced by the adrenals. Hormone levels are best measured in blood tests. Many patients also need a stimulation test called a cosyntropin test to make the diagnosis. Measuring blood renin and aldosterone is often helpful, too. Renin, a substance produced by the kidneys, helps regulate aldosterone.

Alert

Anyone who has adrenal insufficiency should wear a medical bracelet and carry a syringe prefilled with steroids. Adrenal crisis is usually brought on by infection, trauma, or severe stress. The best strategy is prevention and recognizing the subtle symptoms of deficiency.

Treatment for adrenal insufficiency depends on the cause of your condition, but almost everyone requires daily medication to keep the condition under control. In an adrenal crisis, patients may need to administer their treatment by injection.

To replace cortisol levels, you may need to take hydrocortisone, prednisone, or dexamethasone, which are synthetic glucocorticoids, or steroids. If you're deficient in aldosterone, you may need a drug called fludrocortisone (Florinef). As with thyroid hormone replacement therapies, it can sometimes take time to find the right dose, so you may go through a trial period before you do.

The dosages may also need to be adjusted during times of stress since your body won't naturally produce these hormones in response to crisis. In some cases, your doctor may also ask you to increase your salt consumption.

The Thyroid Link

For the thyroid, the depletion of adrenal hormones can have profound effects, most notably the worsening of symptoms. Some experts believe that the adrenal hormones play a role in the conversion of T4 into T3.

Having hypothyroidism can sometimes reveal an underlying problem with adrenal insufficiency. If you are taking thyroid hormone replacement but do not notice an improvement in your symptoms — or you experience a worsening — ask your doctor to check your adrenal glands. You may need simultaneous treatment of both your thyroid and adrenal glands.

Establishing the proper balance of these two treatments is tricky. It often takes some time and effort on both your part and that of your doctor to find the ideal balance of the two treatments. But the effort is well worth it when both conditions are successfully treated.

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