Doug didn’t know what was wrong with him. For months, he’d felt tired, but this was beyond fatigue. It was getting to where just getting up off the couch required a Herculean effort. He’d hoped that getting more sleep would help, but it wasn’t making any difference.
Heather left work and got into her car. She was supposed to drive home and fix dinner for her kids, but she couldn’t summon the energy. She tipped the seat back and closed her eyes. Just a few minutes rest, she thought. A half-hour later, she was still asleep.
When is fatigue just fatigue, and when is it something more serious? Although many things can cause you to feel tired, if you’re suffering from a muscle-deep, undeniable sort of fatigue, you may be struggling with a rare condition called “adrenal insufficiency,” or “Addison’s disease.”
People with this disease often go years without being diagnosed as the symptoms mimic those caused by other conditions, including stress and burnout. A diagnosis can be a lifesaver, however, as it may allow you to find solutions that help you feel more like yourself again.
What Are the Adrenal Glands?
The adrenal glands are small, triangular-shaped glands that sit on top of the kidneys, one on each side. They produce hormones that are involved in several bodily functions, including metabolism, blood pressure, immune response and stress reactions.
Each adrenal gland is made up of two main sections:
- Adrenal cortex: This is the outer region of the gland and is divided into three zones, each of which produces different hormones. All of these are important for helping us to stay alive. Examples of this include cortisol and aldosterone.
- Adrenal medulla: This is on the inside center of the gland. It produces hormones that are important but not critical to life. Examples of this include adrenaline.
When you think of the adrenal glands, usually you think of stress. If a stranger in a dark alley chases you, for example, your adrenal glands will release adrenaline to help you spring into action to save yourself. However, the adrenal glands do much more to contribute to your overall health. They make cortisol, for example, which is involved in the stress response but is also critical to many other processes, including:
- Suppressing inflammation
- Controlling how the immune system manages threats
- Regulating blood pressure and heart rate
- Regulating blood sugar
- Adjusting the breakdown of fats, proteins, and carbohydrates
- Controlling the sleep and wake cycle
- Balancing the sodium and potassium in the blood
- Helping support recovery from infections
The adrenal glands also produce aldosterone, a hormone that helps:
- Regulate the amount of salt, potassium, and water in the body
- Regulate blood pressure
- Maintain the blood’s pH and electrolyte levels
What Is Adrenal Insufficiency?
Adrenal insufficiency, also called Addison’s disease, is a hormonal disorder that occurs when the adrenal glands don’t work as they should. They are “underactive” and fail to produce enough hormones, particularly the hormone cortisol and, sometimes, aldosterone as well.
Doctors classify adrenal insufficiency in two categories:
- Primary adrenal insufficiency (Addison’s disease): A malfunction in the adrenal glands causes low levels of cortisol and aldosterone.
- Secondary adrenal insufficiency: A malfunction in the pituitary gland in the brain causes low levels of cortisol only. The pituitary gland makes a hormone called adrenocorticotropin (ACTH), which signals the adrenal glands to make cortisol. For some reason, it doesn’t send the message.
In both cases, the individual lacks cortisol, which causes difficult symptoms to occur. The disease usually develops gradually, but it can also appear suddenly in cases of acute adrenal failure.
- Chronic adrenal insufficiency: Develops over time and gradually causes worse symptoms.
- Acute adrenal insufficiency: Comes on suddenly and is very serious. It’s considered a medical emergency and must be treated promptly.
What Causes Adrenal Insufficiency?
There are various potential causes of adrenal insufficiency. The most common include:
- Autoimmune disorder: The immune system malfunctions and damages the adrenal glands. For an unknown reason, it begins to see the adrenal cortex as an invader and attacks it. Once a good amount of the cortex is damaged, primary adrenal insufficiency occurs. This is the most common cause of adrenal insufficiency.
- Tuberculosis: This disease can destroy the adrenal glands. It’s a more common cause of adrenal insufficiency in developed countries.
Other less common causes of adrenal insufficiency include cancer cells in the adrenal glands, surgical removal of the glands, genetic defects, amyloidosis (a rare group of diseases), the cytomegalovirus (more common in people with AIDS) and fungal infections.
Secondary adrenal insufficiency is caused by other conditions, including some inflammatory diseases, surgery or radiation on the pituitary gland or cysts and tumors in the pituitary gland. Some medications used to treat rheumatoid arthritis, asthma, and ulcerative colitis can also cause it, including:
- Prednisolone dexamethasone
Symptoms of Adrenal Insufficiency
Symptoms of adrenal insufficiency can often mimic symptoms of other conditions, so it’s not always easy to detect. If you’re feeling more than one of the following, however, talk to your doctor:
- Chronic, lasting, extreme fatigue
- Muscle weakness, possibly muscle pain
- Unintentional weight loss and loss of appetite
- Abdominal pain
- Low blood pressure, possibly fainting or dizziness when standing
- Craving for salt (in primary adrenal insufficiency only)
- Symptoms of low blood sugar like sweating
- Irritability and depression
- Nausea, diarrhea, and vomiting
- Body hair loss or sexual dysfunction in women
- Irregular menstrual periods in women
- Darkened skin on the face, neck, and back of the hands (in primary adrenal insufficiency only); most visible on scars, folds in the skin, and on elbows, knuckles, lips, knees, and toes
These symptoms may get worse in times of stress, such as what may occur in the following situations:
If symptoms get worse or come on suddenly, such as with acute adrenal insufficiency, it’s called an “adrenal crisis” and becomes a medical emergency. Symptoms include:
- Sudden pain in the back, abdomen or legs
- Diarrhea, severe nausea and vomiting
- Low blood pressure and fainting
- Loss of consciousness
- High potassium (hyperkalemia) and low sodium (hyponatremia)
If you or someone you love experiences these symptoms, get to the hospital immediately. If a sudden adrenal crisis is not treated quickly, it can lead to shock, seizures, and coma.
How Do I Know if I Have Adrenal Insufficiency?
Your doctor can tell you if you have this disease. He or she will review your symptoms and your medical history, and then run a blood test to check your levels of cortisol and other hormones. You may receive an injection of either ACTH, which typically stimulates cortisol release, or corticotropin-releasing hormone (CRH), a hormone that normally causes the pituitary gland to tell the adrenal glands to produce cortisol.
The doctor will follow-up with the blood and urine tests to see if the body responded to the injections as expected. He may also perform a urine test to check levels of sodium, potassium, and glucose.
The results of these tests can present a pretty clear picture, and your doctor will probably give you a diagnosis based on the results. But then he or she needs to find out what may be causing the problem. He or she may use imaging tests like X-rays and ultrasounds to look more closely at the adrenal glands as well as additional skin tests and blood tests, which can help him determine if the disease is related to tuberculosis or an autoimmune condition.
If the doctor determines you have secondary, rather than primary, adrenal insufficiency, he or she may run a CT scan or MRI to check the pituitary gland.
Standard Treatments for Adrenal Insufficiency
Once the disease is diagnosed, treatments follow that help replace the hormones that you are missing. The dose is adjusted for each patient as the balance of hormones is important to proper body function. If you have primary adrenal insufficiency, you may be missing both cortisol and aldosterone, so you will likely take medications to replace these hormones. Those with secondary adrenal insufficiency would need only cortisol replacements.
Those who go through an adrenal crisis are usually treated with immediate IV injections of hormones. Doctors also typically give patients with adrenal insufficiency an injection they can carry with them should they become drastically low on cortisone. This is a possibility in times of stress, fever or dehydration.
In addition to hormone replacement therapy, those with primary adrenal insufficiency can also help themselves feel better by following a diet rich in sodium. Because they are low in aldosterone, which helps balance sodium in the body, they may be sodium deficient.
Calcium is another nutrient that is important as medications that replace cortisol can increase the risk of osteoporosis or bone thinning. Your doctor will probably tell you to be sure and eat foods high in calcium and vitamin D to support bone health.
Mayo Clinic. (2017, August 4). Addison’s disease – Symptoms and causes. Retrieved from https://www.mayoclinic.org/diseases-conditions/addisons-disease/symptoms-causes/syc-20350293
NIDDK. (2014, May 14). Adrenal Insufficiency & Addison’s Disease | NIDDK. Retrieved from https://www.niddk.nih.gov/health-information/endocrine-diseases/adrenal-insufficiency-addisons-disease