National Adrenal Diseases Foundation

What is Adrenal Disease?

Dr. Thomas Addison discovered the first adrenal disease in 1849. Addison's disease is named for him. Information about Addison's disease is taught in virtually every medical or nursing school program but is so rare few practitioners have personal experience helping patients manage it. Traditionally it was thought that there would only be 1 case per 100,000 people. A recent study indicates that the number of cases is 11 to 14 in 100,000 people of European descent.

Dr. Hans Selye devoted his life to understanding how the adrenal gland helps the body adapt to the stresses of life. There are bad stresses (loss of a spouse, abscessed tooth, or job loss), good stress (a new job or first kiss) and combination stresses (getting married, having a baby). In each case, the body experiences stress and must learn how to adapt. The amount of stress depends upon the stressor, the individual personality type, the ability to see a way to reduce the stress and/or the ability to see a way to adapt to it. For example, two people may lose their job - Person A becomes angry and depressed. He becomes unable to function or find new work due to the job loss which he perceives as unfair and stressful. Person B quickly accepts the situation. He creatively begins job hunting and easily finds new employment.

Each kind of stress affects a different part of the body. For example, “Running produces a stress situation, mainly in our muscles and cardiovascular system. To cope with this, we first have to limber up and get these organs ready for the task at hand; then for a while we will be at the height of efficiency in running, but eventually exhaustion will set in…Such exhaustion is reversible and after a good rest we will be back to normal. We first get into the swing of things, then we get pretty good at them, but finally we tire and lose our acquired efficiency.”

How does the body adapt to stress?

There are three organs that allow the body to adapt to stress. The hypothalamus which receives signals from the central nervous system indicating stresses and what needs to be done to adapt. It sends a hormone (CRF or Corticotrophin – Releasing Factor) through the blood stream to the pituitary gland. When the pituitary gland receives CRF it releases adrenocorticotrophic hormone (ACTH) through the blood steam to the adrenal gland causing it to release several other hormones which help stabilize the body from stress. This is called the HPA axis. (medcram video 1) (medcram video 2)

The list below shows which part of the adrenal gland releases the hormone, the released hormone, and the activity controlled by this hormone. Click on the word symptoms to see how the body responds to too much or too little of each hormone.

  1. Adrenal Cortex
    1. Cortisol - NADF symptoms
      1. Metabolizes fat, protein and carbohydrate through gluconogenesis
      2. Controls immune response such as inflammation rheumatic diseases and allergies
      3. Controls blood sugar levels through gluconoeogenesis
      4. Regulates Bone and collagen (muscle, tendon and joints) formation
      5. Coordinates development of fetus during pregnancy
    2. Aldosterone - Mineral cortisol - NADF symptoms
      1. Blood pressure
      2. Electrolyte balance which affects ability of cells to receive nutrient
      3. Feeling confused and fatigued and having muscle twitches and seizures.
    3. DHEA - Androgens Mayo clinic list of symptoms.
      1. Partially regulates estrogen in women
      2. Partially regulates testostrone in men
  2. Adrenal Medulla
    1. Epinephrine (adrenalin) and norepinephrine (Noradrenalin)
      1. Enables quick response of various organs in stress (fight, flight, or freeze)

What is the Relationship of Addison's to other Adrenal Diseases?

The graph on the right shows the relationship between Addison's disease, Cushing's disease and other adrenal diseases. In some cases the HPA axis produces too much cortisol and in other case none at all. Adrenal diseas can be catagorized by how much surplus and how much deficit there is in adrenal output, and what causes the malfunction. A WebMD website suggest "75 percent to 90% of all doctor's office visits are for stress-related ailments and complaints."

Adrenal disease can be broadly divided into four categories with two producing too few hormones and two producing too much. (2014 TV feature on Adrenal Disease.)

  1. Addison's Disease - Little or no steroids produced to stabilize the body
  2. Adrenal deficiency - Insufficient steroids to stabilize patient when experiencing stress
  3. Stress - High level of steroids throughout the day without restabilization to non-stress condition. Dr. Robert Sapolsky, professor of biology, neuroscience, and neurosurgery at Stanford University, published Why Zebra Don't Get Ulcers in 1994 and describes how stress amplifies many illnesses.
  4. Cushing's - Steroid levels are too high. NADF description

Timing of Hormones is Critical

In the case of most illnesses or diseases, medicine is administered to keep a constant titer (concentration level) in the body such as one pill every 6 hours. Since the adrenal gland releases hormones to prepare for anticipated stresses, it releases the highest level of hormones early in the morning to prepare for starting the day. As the day progresses, hormone levels decrease so the body can go to sleep without difficulty. If the person works a night shift, the levels shift to reflect the different schedule. This is called a Circadian cycle.

Thus, the replacement dosage is greater when the person awakens and tapers off so they can finally go to sleep.

Three Important Issues for Addison’s patients

Manual Replacement Levels of Hormone

Hydrocortisone is a direct replacement for cortisol. It can be used in three ways.

  1. As a medicine to control inflammation and immune responses such as allergies.
  2. As a manual replacement for what the normal adrenal gland would automatically produce.
  3. As a stabilizer when the Addisonian is under very high levels of stress. This includes: illness stress, Surgical and Dental Stress, and emotional stress.

Most medical practitioners are very familiar with the use of steroids to control inflammation and immune responses. Replacement and stabilization use is less familiar.

A distinction must be made between normally expected daily stress and high levels of stress whether predictable or unexpected. For normally expected daily stress the Addisonian must manually replace only what the healthy adrenal gland would produce on a regular basis. In the case of predictable high stress such as medical or dental surgery, Addisonians can increase their medication to prepare for the additional stress. In the case of sudden, unpredictable stress (such as when the body is unable to keep medication in the stomach or a major injury or illness) an IV or intra muscular shot of steroids may need to be injected as quickly as possible. This is an example of Addison Crisis.

A recent British Medical Journal editorial indicated that 15% of Addisonians die in the emergency room because of delays in administering a steroid injection. NADF has a current campaign to publicize the need to reduce these deaths. If there is any indication of Addison’s disease, it is recommended that emergency room personnel should draw blood, administer steroids and then diagnose after administering the steroids. It is essential to use the body’s natural stress recovery system to help stabilize the patient while other procedures are being performed. It is also essential that Addisonians provide information to the Emergency Response teams that they have Addison's disease so the ER teams knows how to respond.

Importance of Patient Education and and Accepting Responsibility for Cortisol Replacement

It is difficult for a physician to prescribe specific amounts and times for steroids to be given which would always meet the daily demands of an Addisonian. Expected stresses are different each day and each individual has different abilities to view and resolve stresses as they occur, so patients may need different levels of hormone replacement. They need to follow a basic principal: "Take a minimal replacement as needed for stability but keep it as low as possible to minimize side effects." Since the only person able to know the individual’s stress and his/her ability to adapt is the patient, they must be educated to know how to recognize body response and the amount of medication they must take to stabilize. There is a very important need in each geographical area to have a health education center to help patients access information on adrenal disease and a support group where patients can learn from each other. This is especially important since most practitioners may not have sufficient patients to justify the development of these resources independently.

Frustration in Receiving a Diagnosis when a Patient has Addison's

Dr. Mimi Guarneri , founder of the Scripps Center for Integrative Medicine indicates that modern western medicine practitioners are trained in the following process:

  1. Ask patient “What is your chief complaint?”
  2. Listen to response.
  3. Form hypothesis about cause of complaint.
  4. Perform diagnostic test to confirm hypothesis.
  5. Prescribe solution to solve complaint.

Physicians are trained to distinguish between an illness and a disease.

A disease is defined as having a specific group of symptoms with an identifiable biological cause that can be readily established. It is often chronic in that it is a serious long-term condition that cannot be cured, only managed. An illness like the flu or cold, leaves the patient with many very real but generally vague symptoms like “I feel bad all over”. It generally has a sudden onset and in most cases can be cured relatively easily. Family medicine practioners see many illnesses and often refer diseases to specialists. Unlike most diseases, Addison’s presents itself with many vague symptoms since the hormones it produces regulate virtually every cell in the body in many different ways. Practitioners can be misled into looking for an illness by this rare, deceptive disease and not request the needed diagnostic tests. Thus, the age-old caution, if you start with the wrong hypothesis you will reach the wrong conclusion. Stated another way – Patients find it extremely frustrating and go to many practitioners before they are finally diagnosed.

An example may illustrate. A patient with five pages of symptoms was told by a physician: "Come to me with one symptom and I can cure it. Five pages and you are a hypochondriac." When the patient returned a year later with the same symptoms the physician was annoyed since he expected the body to have healed the illness. As soon as an Endocrinologist ordered an ACTH stimulation test, diagnosed Addison's disease, and prescribed a minimum dose of hydrocortisone all five pages of symmptoms disappeared.

Addison's Disease

Addison's Disease

Addison's Disease

Addison's Disease