Kathryn Jean Lucas, MD
611 N 35th St
Morehead City, North Carolina 28557

inside health

Sex, Stress, and Salt STALKING THE WILD ADRENAL GLANDS

By: K. Jean Lucas, M.D.

Joan had always been healthy her whole life. One day at work she noticed that she would feel like she was going to faint if she stood up. These sensations became more severe after she had bronchitis. Eating salty foods seemed to help some. Her skin was becoming darker even though she hadn’t been to the beach in over six months. Her physician tested her for adrenal insufficiency. Her cortisone levels were very low. One she was started on replacement therapy, her life became normal again.

What are Glucocorticoids?

Glucocorticoids, hormones produced by the adrenal glands, are part of a larger chemical group known as steroid hormones. Hydrocortisone (or cortisone) is the primary glucocorticoid secreted by the adrenal gland. The adrenal glands are small triangular organs located on the top of the kidneys. The pituitary gland at the base of the brain sends out a signal to the adrenals to secrete cortisone. This pituitary hormone, ACTH, is required for the adrenal to produce the correct amount of cortisone in every situation.

Glucocorticoids, produced by the adrenal gland, maintain blood pressure and energy supplies to the body on a daily basis and prepare the body for stressful events. These steroids increase the energy supply to the body by causing the liver to release sugar. If the stored supplies of sugar are not adequate, these hormones will break down the tissues of the body (such as muscle) in order to provide the appropriate material for more energy production.

Synthetic versions of these glucocorticoid hormones are used to treat various diseases such as asthma, arthritis, and lupus and to prevent the body's rejection of organ transplants. Medications in this category go by the following names: Prednisone (Deltasone), Dexamethasone (Decadron), and Methylprednisolone (Medrol).

The main function of the glucocorticoid medication is to prevent inflammation in the body and suppress an overactive or inappropriate immune system. When the body is attacking itself in autoimmune diseases such as lupus, rheumatoid arthritis, or polymyositis (inflammation of the muscle), glucocorticoids decrease the ability of these cells to attack the body. In order to prevent damage from the autoimmune disease, the whole immune system of the body is affected leading to an increased tendency for infection.

High doses of glucocorticoids either taken as medication or excessively produced by the body over time will cause weakening and deterioration of the muscle, bone, and other body tissues. This effect is called a catabolic or "breaking down" effect. High doses of glucocorticoids used to treat auto-immune diseases or asthma can have a severe effect on the body over time. The muscles can become weaker and smaller. The bones will lose calcium and be prone to osteoporosis. The tissues supporting the skin will become more fragile leading to increase in bruising and damage to the skin. These steroids also increase the storage of fat in the middle of the body.

Glucocorticoids also cause the kidneys to hold onto salt. With normal amounts of these steroids, this salt retention properly maintains normal blood pressure and blood flow in the body. However, if the amount of the glucocorticoid is excessive, the high salt retention that results can lead to swelling and high blood pressure. In those patients with weak hearts, the excessive fluid accumulation can result in heart failure.

Normally, in times of stress, the glucocorticoids made by the adrenal mobilize extra sugar in order to provide energy to deal with the stress. High doses of these steroid hormones may lead to an elevation of blood sugar in those people who are predisposed to get diabetes. If you have a family history of diabetes, have had problems with blood sugar in the past, or are overweight, taking steroids may cause your blood sugar to be excessively high. Symptoms of a high blood sugar include: excessive thirst and urination, blurred vision, dizziness, fatigue, numbness and tingling in the hands and feet.

What is Adrenal Insufficiency?

When taking large doses of steroid medication to treat a disease, the patient on glucocorticoids will undergo suppression of his or her own production of these hormones by the adrenal gland. This suppression actually occurs at the level of the pituitary gland. ACTH production by the pituitary gland is decreased or stopped by taking or producing large amounts of glucocorticoids. As long as the patient is on the higher than normal doses of the steroid hormones, the body is supplied with enough hormones to maintain its daily needs. However, as the disease which is being treated by the steroids improves, the dose of the steroid is gradually reduced by your physician. If the steroid dose is tapered slowly enough, the pituitary production of ACTH and the adrenal glands are able to return to normal functioning. The adrenal may then resume its previous production of steroid hormones. However, the pituitary and adrenal may still not be able to produce enough steroids in response to stress. For up to one year after being on high dose glucocorticoids, one's adrenal may not be able to respond to stress. The inability to adequately produce enough glucocorticoids is called adrenal insufficiency. Symptoms of adrenal insufficiency are: nausea, dizziness, fatigue, salt-craving, and weakness.

The most common cause of adrenal insufficiency is having been on high dose steroids for many weeks. Some people, however, develop primary adrenal insufficiency. In this condition, the adrenal fails to function normally either as a result of antibodies attacking the adrenal, tuberculosis, a severe fungal infection, hemorrhage into the adrenals, or the surgical removal of the adrenal glands. People with primary adrenal insufficiency (also called Addison's disease) have a permanent defect in the ability to make steroid hormones and must be on cortisone for the rest of their life. When the pituitary is not working properly, ACTH production, the signal telling the adrenal to work, may diminish; therefore, the adrenals do not produce enough cortisone. This condition is called secondary adrenal insufficiency. The pituitary production of ACTH may decrease because of a tumor, cyst, previous pituitary surgery, or by suppression from use of steroid medications. When the pituitary is the cause of the low cortisone production, other hormones are also effected. Women with a pituitary problem may stop having periods. Thyroid hormones may also be low.

How is Adrenal Insufficiency Diagnosed?

Clues to the diagnosis of adrenal insufficiency may be the symptoms a patient is having (such as nausea, dizziness, or fatigue), abnormal levels of sodium or potassium in the blood, or a history of other hormone abnormalities (such as a pituitary tumor) associated with decreased cortisone production. The adrenal production of cortisone is tested by giving CORTROSYN in the vein or in the muscle. This hormone is similar to the ACTH produced by the pituitary. The cortisol level should increase within 30-60 minutes after the injection is given. If the response is not enough, then other testing may be done to determine the cause of the problem, whether from the adrenal itself or a pituitary disorder.

Anyone on cortisone medication for a chronic disease or who has primary adrenal insufficiency should wear a medical alert bracelet saying, ADRENAL INSUFFICIENCY. A card in your wallet giving your home address, phone number, physician's name and number will also be helpful in case of an accident. The person attending to you will then know to give you with a large stress dose of hydrocortisone to help in your recovery from the stress on your body.

In times of stress from an illness, accident, injury, or psychological cause, the maintenance dose of cortisone (the dose you are on usually) will need to be increased as the normal adrenal gland would. Usually, the increase means doubling the dose you normally take; however, this therapy needs to be individualized. All patients should confer with their physician about the dose they should take if they become ill. Patients with primary adrenal insufficiency should also have an injectable form of hydrocortisone. This injection would be given if the person who usually takes oral cortisone is unable to keep the additional stress dose of cortisone in his stomach because of nausea and vomiting. Increasing fluid and salt intake during times of illness will also help in the recovery process.

In patients with primary adrenal insufficiency, the adrenals also do not produce mineralocorticoids. Aldosterone is the main mineralocorticoid. This hormone helps maintain salt balance, normal potassium levels, and blood pressure. The synthetic form of this hormone is called, FLORINEF. Because its effect may last more than one day in the body, it is usually not given every day. Many patients only need one-half of a tablet every other day. Symptoms of having taken too much florinef are swelling, high blood pressure, and low potassium which can cause muscle weakness and cramping.

The other group of steroids made by the adrenal are androgens or male hormones. These steroids are very weak male hormones. Research is ongoing regarding their significance in aging of the body and whether or not they should be replaced in adrenal insufficiency. These adrenal androgens are what most people think of when they hear the word "steroid". Athletes who misuse "steroid" hormones are actually taking too much male hormone or testosterone. Testosterone is in the family of steroid hormones and is secreted by the testes and ovary.

If you are currently on steroid hormones for treatment of a chronic disease, you should try to actively prevent some of the side-effects associated with cortisone by doing the following:

	Exercise frequently and do weight training to improve muscle mass after clearing this with your physician
	With your physician's guidance and if you do not have kidney stones, increase the amount of calcium in your diet or take calcium supplements. Aim for 1500mg of calcium per day. (For example, 8 ounces of skim milk provides 300 mg of calcium.)
	Try to be on as low a dose of the cortisone preparation as possible. Agree to add other medications to your regimen if the dose of the cortisone can be decreased by the change.
	Follow-up frequently with your physician
	Take estrogens (if you have no medical conditions that prohibit it) at the onset of menopause to prevent further bone loss.
	You may need another medication for osteoporosis if you have had significant bone loss over the years from taking high doses of cortisone.

If you have adrenal insufficiency, you should keep the following points in mind:

	Not receiving the appropriate dose of cortisone may be dangerous and life-threatening
	Always take the brand name of the cortisone preparation you are prescribed. Make sure your pharmacist is aware of your needs since some pharmacies do not carry all brands of cortisone.
	Maintenance doses of cortisone do not cause the breakdown effect of the large doses that are used to treat diseases. The dose taken in order to replace what is adrenal is supposed to make does not cause osteoporosis.
	Take your medication daily as prescribed by your physician
	Do not wait until your prescription has expired or you are on the last dose of your cortisone preparation to follow up with your physician. Schedule regular follow-up appointments so the correct dose of cortisone is continued.
	Keep some additional medication, oral and injectable with you at all times, especially when you are away from home.
	Never stop or lower your medication without consulting with your physician.
	Because you will need additional cortisone before a surgical procedure, always alert your physician to plans for surgery.

In Case of Illness or Emergency:

	If you are sick, double your usual dose of cortisone. Call your physician immediately to receive further instructions and treatment.
	Be sure to drink additional fluids containing salts (coke, Gatorade, bouillon) when you are ill. Drinking only water will dilute the salts in your body and cause you to feel worse. Dizziness, weakness, and nausea are symptoms of inadequate amounts of cortisone and/or florinef in your body.
	You may need additional florinef in extremely hot weather when you sweat profusely. This additional florinef should not be taken without approval from your physician.
	Be sure to get an annual flu shot to prevent this type of illness. A Pneumovax shot every five years will prevent your acquiring a common type of pneumonia.

For further information on adrenal diseases, you may contact:

National Addison’s Disease Foundation
505 Northern Boulevard
Great Neck, New York 11021
(516) 487-4992

Send mail to Seth.Medlin@BeachDoctor.com with questions or comments about this web site.
Send mail to Dr. Lucas lucas@BeachDoctor.com
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