Chapter
14

Adrenal Gland Diseases

In This Chapter

• Understanding the thyroid-adrenal connection
• Recognizing adrenal disease symptoms
• Best testing strategies
• Healing underperforming adrenals
• Dealing with overperforming adrenals

As explained in Chapter 7, it’s possible to be hypothyroid but labeled “normal” on blood tests because the ranges used by most labs are too broad. To make life even more complicated, you can be hypothyroid and labeled “normal” on blood tests because your thyroid really is functioning normally. This paradox stems from a pair of endocrine glands called adrenals that your thyroid relies on to be effective.

Spotlighting Your Adrenal Glands

The adrenal glands are two small triangle-shaped lumps of tissue residing over your kidneys.

The adrenal glands are divided into four sections: an outer cortex with three layers, and an inner medulla. Each section produces hormones regulating bodily functions vital to your health. These can be summarized as salt, sugar, sex, and stress:

• Salt: The outermost cortex layer produces hormones such as aldosterone that control the amount of sodium and water in your body, and regulate your blood pressure.
• Sugar: The middle cortex layer makes the critical hormone cortisol, whose many functions include regulating your blood’s glucose levels (along with your pancreas), controlling your blood pressure (along with aldosterone), healing inflammations, and enabling your thyroid hormones to enter cells.
• Sex: The innermost cortex layer creates the sex hormones testosterone and estrogen (as a backup for your testicles or ovaries, which produce the same sex hormones).
• Stress: The medulla produces adrenaline, a hormone that’s triggered when you’re in a dangerous or unexpected situation. Adrenaline increases your heart rate, expands your blood vessels and air passages, and makes other subtle changes that help you react instantly to whatever trouble comes your way by either battling or running (commonly called fight or flight).

The adrenal glands.
(Licensed from Shutterstock Images)

When a Good Thyroid Seems Bad

The adrenal hormone most important to your thyroid is cortisol, which plays two vital roles. First, cortisol helps convert the T4 that leaves your thyroid (or that you’re taking via medication) into T3. That’s a vital function, because T4 is merely a storage state; your body can only make use of T3. In addition, cortisol gives T3 the ability to penetrate a cell’s membrane. Once inside a cell, the T3 powers up the cell’s mitochondria, providing your body with the energy it needs.

The partnership between your thyroid and your adrenals works beautifully when both glands are healthy. If your adrenal glands start underperforming, however, there won’t be enough cortisol to convert T4 into all the T3 you need. Worse, there won’t be enough cortisol to allow T3 to penetrate your cells. That means even if your thyroid is doing its job perfectly, your body won’t benefit from it because a certain amount of T3 will be blocked from accessing your mitochondria.

Conversely, if your adrenal glands are overperforming, then you’ll have too much cortisol in your system, and that’s just as much of a problem, because excessive cortisol prevents mitochondria from absorbing thyroid hormones. The result is the same—the mitochondria don’t get recharged, depriving you of energy vital to your health.

In either case, you’ll end up in a hypothyroid state. Your thyroid blood tests will all show up as normal—because your thyroid really is healthy and performing its job perfectly. What needs to be diagnosed and treated are your adrenal glands.

Underactive Adrenals

If your adrenal glands are underperforming, you may have Addison’s disease (also called adrenal insufficiency). This refers to a physical problem with your adrenals, such as a genetic defect, or an autoimmune disorder in which your adrenals are being attacked by antibodies. Addison’s disease is relatively rare, affecting 1 to 4 out of every 100,000 people.

Alternatively, you might have a problem with your pituitary gland, which controls the activity of your adrenals via a hormone called ACTH (also known as adrenocorticotropic hormone or corticotropin). If for some reason your pituitary starts producing too little ACTH, your adrenal glands—even though perfectly healthy—will underperform because they’re following the “orders” conveyed by the ACTH. This is called secondary adrenal insufficiency, as the cause is indirect—it’s really your pituitary that has the problem, but your adrenals behave as if they’re ailing. Further, if this condition is left untreated, over time your adrenals really will become damaged, as they’ll shrink from lack of use. This condition is much more common than Addison’s disease.

Another cause for underperformance is a shortage of the chemical building blocks that fuel hormone production. For example, your adrenals require cholesterol to make cortisol. If your body is having trouble getting cholesterol to your adrenals, or if you’re taking medication that interferes with cholesterol, your adrenal glands won’t have enough raw material to do their job.

As another example of underperformance, your adrenal glands are secondary suppliers of the sex hormones testosterone and estrogen, essentially backing up the primary production from your testicles or ovaries. At the age when women begin menopause and men’s testicles start producing less testosterone (sometimes referred to as andropause), the adrenals are required to pick up the slack. If there was a barely adequate amount of chemical ingredients to work with to start, the increased demand for sex hormones will force the adrenals to cut back on other hormones—including cortisol. For this reason, if you’re going to have an adrenal problem, it’s most likely to happen around age 45-55.

Finally, some doctors believe the number one source of adrenal problems is adrenal fatigue, or hypoadrenalism, which occurs as a three-stage process. When life hands you the occasional hardship, your adrenals will produce extra hormones to help you get through it and will then return to normal. This first stage is called compensation, and is perfectly healthy. If such strains become frequent, though, or if they become exceptionally severe, your adrenals are likely to overreact and produce more hormones than are good for you. This stage is called overcompensation. If the stress then continues over a long period of time, the wear and tear on your adrenals may eventually cause them to lose the ability to produce even normal levels of hormones. This third stage is called decompensation.

If this happens to you, your adrenals are likely to subtly underperform—not create symptoms as severe as those of Addison’s disease, but still impair your quality of life. The good news is adrenal fatigue can often be managed with over-the-counter remedies that have virtually no side effects.

Identifying Underactivity

Because your adrenal glands regulate blood sugar, salt, blood pressure, and stress responses, there are some quick and easy things you can do on your own as a first rough check on whether they’re underperforming.

First, try delaying or skipping a meal and see if it’s any harder to do than usual. If so, that could mean you’ve become hypoglycemic—low on blood sugar—which in turn could mean a shortage of cortisol. Also notice if you have any other symptoms of hypoglycemia, which include frequent hunger (especially for sugar or starch), fatigue, impaired judgment, confusion, nausea, anxiety, and shakiness. In addition, note whether you’ve developed strong cravings for salt. That can indicate a shortage of the adrenal hormone aldosterone.

Next, perform a quick check on your blood pressure. It’s easy to take your body’s management of blood pressure for granted; but when you stand up, there’s actually quite a bit of complex internal orchestration involved to prevent your blood from abruptly dropping from your brain into your feet. When the adrenal hormones cortisol and aldosterone are low, this mechanism isn’t as effective; so try lying down for a few minutes and then abruptly rising. If you become dizzy, feel weak, and/or see spots, it’s probably because more blood rushed down from your brain than is normal.

Thyroidian Tip

If you’d prefer a more formal version of the blood pressure test, tell your doctor that you want her to check your orthostatic hypotension. She’ll have you lie down, hook you up to a blood pressure machine, and then ask you to stand. If you’re healthy, your systolic (top number) blood pressure will go up 5-10 points. But if you’re low on adrenal hormones, it’ll drop 10-25 points.

Another test you can perform easily on your own is checking your fight-or-flight response, which is regulated by the hormone adrenaline. First sit in front of a mirror and turn off the light for a minute, which will make your pupils open wide. Then shine a flashlight across (but not directly into) your eyes, and watch how your pupils react for the next 30 seconds. Your irises should instantly contract in response to the light increasing, and stay contracted. If you’re low on adrenaline, however, it’s likely that your irises will contract briefly but then expand; or waver back and forth between contracting and expanding.

One other way you can identify underperforming adrenals is paying attention to your skin (and especially your torso’s epidermis). A combination of low cortisol and high ACTH can stimulate the cells that control skin pigmentation, resulting in dark, irregularly shaped spots a few inches long—sometimes called “café au lait spots” because they look like spilled coffee.

Testing for Underactivity

If you have reason to suspect an adrenal problem, you should visit an endocrinologist for formal testing. Your doctor will test your cortisol levels. Unfortunately, this isn’t a straightforward procedure, because cortisol varies over the course of a day. If you’re on a mainstream schedule, your cortisol level will rise in the morning, peaking at around 7 A.M., and then sink to very low levels at night. Your doctor will therefore probably take two blood tests—one in the morning and the other in the afternoon—noting the time of day for each so that can be factored in when evaluating the lab results.

If you happen to work at night and sleep during the day, however, your cortisol patterns might be reversed. And if your schedule shifts from day to day, that makes taking just a couple of blood tests even more problematic. To get around this, some doctors will ask you to collect your urine over a 24-hour period. The total is then tested to determine the cortisol level on average for the entire day. The downside is there’s no information on highs and lows—that is, how much the cortisol varied from one time of day to another. Therefore, this test is most useful as a supplement to the twice-a-day blood test.

Another approach is what’s called a cortisol challenge test. This involves measuring your cortisol level; giving you a small (typically 25 microgram) dose of ACTH, which is the hormone your pituitary gland makes to stimulate adrenal activity; waiting an hour or two; and then measuring your cortisol level again. If your adrenal glands are healthy, they should have produced at least twice as much cortisol in response to the ACTH. If they didn’t, it’s a strong indicator they’re ailing. This is an excellent way of obtaining precise information about adrenal performance.

This technique is also useful if you have physical symptoms of adrenal underperformance but your cortisol levels don’t appear significantly off-kilter on standard blood tests. Even if you have a tolerable cortisol level when you’re sitting calmly in a doctor’s office, the challenge test will show if your adrenals are inadequate when faced with stress or other demanding situations that call for extra hormone production.

One other available option is salivary cortisol testing. This allows you to enjoy a normal day, but take a sample of your saliva every 4-6 hours (using a kit supplied by your doctor), marking the time each sample is taken. Adrenal hormones in your saliva are roughly proportional to those in your blood, so the test results allow your doctor to track your cortisol levels throughout the day. The main disadvantage of this method is hormones attach to red blood cells. It’s common to have tiny amounts of blood in the saliva, and even if they’re too small to see, they can skew results. But your doctor can instruct you on ways to minimize this problem (such as not brushing your teeth the day of the testing).

Thyroidian Tip

It’s possible to be hypothyroid from thyroid disease alone and from adrenal disease alone. But you shouldn’t discount the possibility of having both diseases. If your thyroid starts failing, your adrenals may work harder in an attempt to compensate and eventually become damaged from the strain. So if you notice symptoms of both diseases, it might not be your imagination, and you shouldn’t hesitate to get tested for both.

Further, consuming external cortisol can create new health problems. Cortisol is an anti-inflammatory, so it will stop inflammation wherever it ends up in your body. Since inflammation is an important tool your body uses to repair itself, prolonged use of cortisol replacement risks erosion of your intestinal lining and esophagus.

If your adrenal glands are severely damaged—for example, if you have advanced Addison’s disease—then taking cortisol pills for life may be your only realistic option. If you have a choice, though, it’s better to first try making your adrenals stronger and more efficient.

For example, taking the herb ashwagandha (Latin name withania somnifera) poses virtually no risk of side effects; and it increases the odds of your adrenal glands restoring themselves to normal over time. (Plus if you have other glands that are ailing—including your thyroid—ashwagandha is likely to help them, too.)

Another simple but helpful aid is licorice, which is powerfully effective at delaying the conversion of cortisol to cortisone. This helps you hang on to the cortisol your body is making on its own.

Yet another potential solution is taking adrenal tissue—typically from cows—in tablet form. Some studies have found that if you orally ingest a gland, your body will make use of it to shore up your own version of the gland.

Finally, you can make lifestyle changes that ease the strain on your adrenals, such as eating healthy, cutting down on stress, and eliminating toxins. For details, see Chapters 18 and 22.

Overactive Adrenals

As bad as it is to have too little cortisol, it’s even worse to have too much of it. The latter condition is called Cushing’s syndrome, or hypercortisolism. Cushing’s syndrome often results from cortisol-based medication such as prednisone. Because of its anti-inflammatory properties, cortisol is used to treat such illnesses as asthma, rheumatoid arthritis, lupus, and ulcerative colitis. That’s normally fine; but if you take high doses of cortisol for a prolonged period, it will start to break down your tissues, and may do damage to your heart and bones. If this occurs, you can simply taper off your current medication and then switch to one that’s not cortisol-based.

More serious is when your adrenal glands are overproducing cortisol. This is rela-tively rare, occurring most often in adults aged 20-50. It also happens in women in the last trimester of pregnancy, as that’s a period of substantial hormone changes. Causes include autoimmune disease, in which antibodies attack your adrenals and cause them to enlarge.

Alternatively, your adrenal glands’ cells can spawn tumors called pheochromocytoma—growing either on the glands or outside of them—that produce hormones independently. The combination of hormones from both your adrenals and the tumors will put you beyond healthy limits.

A more indirect cause that ends up creating the same effect is your body having too much ACTH. This can happen if you’re taking medication that contains a high amount of ACTH. It can also result from adenomas (non-cancerous tumors) that start growing on your pituitary gland and increase ACTH output. In either case, the extra ACTH forces your adrenals to produce more cortisol than is good for you.

Crash Glanding

The pituitary gland isn’t the only source of ACTH. Extra ACTH can also stem from cancerous tumors—for example, in the lungs or intestines. When this occurs, the symptoms of Cushing’s syndrome are actually a blessing, because they’ll tip off an astute doctor to the existence of cancers that must be located and destroyed.

Alternatively, you can lead your adrenals to develop bad habits. For example, if you’re an athlete who trains hard, you’re forcing your adrenal glands to produce a lot of extra cortisol. That’s usually not a problem if you take care to include adequate periods in between sessions for your body to rest, recover, and reset. But if you’re overtraining day after day, your adrenal glands can become so used to overgenerating cortisol that they get stuck at that higher setting and will continue to overproduce even if you stop exercising.

Identifying Overactivity

The primary symptom of Cushing’s syndrome is gaining a lot of weight, especially in the middle and upper body. Fat is prone to gather around the neck and back (between the shoulder blades). In children, the obesity is accompanied by a slowed rate of growth. In addition, there’s often facial swelling that creates a rounded “moon face.” At the same time, loss of lean body mass results in relatively thin arms and legs.

Further, too much cortisol thins the skin, making it easy for mere bumps to bruise or tear skin. The fragility of the skin, coupled with the weight gain, can also result in pink or purple stretch marks on the torso, arms, buttocks, thighs, legs, and/or breasts. Thinning, brittle hair and hair loss is common as well.

Because cortisol reduces immune responses, wounds may happen more often and take an extra long time to heal. You could also start developing aches and pains in your hips, shoulders, and lower back. And you might be the first to catch any illness going around and among the last to recover.

Your adrenals producing excess adrenaline can heighten and intensify your emotions, making you feel anxious, euphoric, depressed, or even psychotic.

If you’re a woman, your adrenals overproducing sex hormones can cause your menstrual cycles to become irregular, or to stop altogether. Further, you might get unusual patterns of hair growth and facial acne. And if you’re a man, the overdose of cortisol can reduce your sex drive and impair erections.

Additional symptoms include high blood sugar, increased thirst and urination, fatigue, weakness, and hypertension.

Cushing’s syndrome must be taken seriously. If left untreated for a long time, it can lead to diabetes, osteoporosis, heart disease, and death.

Other ways to test your cortisol levels are to have you collect either your urine or your saliva over a 24-hour period. If your doctor determines there’s a problem, she’ll order a CT scan of your adrenals and MRI of your pituitary gland to hone in on it, looking for anything out of the ordinary such as growths on the glands.

Treating Overactivity

There are some drugs that either lower the body’s production of cortisol or lower the effects of cortisol, such as ketoconazole and metyrapone. However, their effectiveness is limited.

Therefore, the most common solution is surgery. For example, if an adenoma is found on the pituitary gland, the growth will be cut out. If the surgery restores your glands to health, then nothing more needs to be done.

However, if the surgery either removed or damaged your pituitary or adrenal glands, you’ll need to deal with a shortage of cortisol (as described earlier in this chapter).

The Least You Need to Know

• If you have clear hypothyroid symptoms but your thyroid tests are normal, you may have adrenal gland disease.
• Symptoms of underperforming adrenals include low blood sugar, salt cravings, dizziness when abruptly standing up, and coffee-stain-like spots on your skin.
• Symptoms of overperforming adrenals include weight gain, thin skin, high blood sugar, thirst, and extreme emotions.
• Treating overperforming adrenals usually requires surgery.