Overactive adrenal glands are a complex disease with a very diverse etiology. We can distinguish between adrenal glucocorticoid and mineralocorticoid hyperactivity, as well as androgenic or estrogenic hyperactivity. What are the causes and symptoms of an overactive adrenal gland? How is her treatment going?

An overactive adrenal glandis when the adrenal gland produces too much of one or more of the hormones that the adrenal gland produces: cortisol, aldosterone, androgens, and adrenaline. We can distinguish between glucocorticoid and mineralocorticoid hyperactivity of the adrenal glands, as well as androgenic or estrogenic hyperactivity.

Glucocorticoid hyperactivity of the adrenal glands

Glucocorticoid hyperactivity of the adrenal glandsis a group of disease symptoms resulting from an excess of cortisol in the body. It is also referred to ashypercortisolism . Causes include Cushing's disease of hypothalamic or pituitary origin, Cushing's syndrome due to adenoma induced hypercortisol secretion, small or large nodular hyperplasia or adrenal cancer, as well as ectopic production of CRF or ACTH and exogenous administration of glucocorticoids.

  • Pathophysiology

The present symptoms result from the influence of excess glucocorticosteroids secreted by the adrenal glands on the metabolism. These hormones cause excessive retention of sodium and water by the kidneys, increased urinary potassium excretion, increased gluconeogenesis with subsequent hyperglycemia, and increased protein catabolism. They also contribute to the impairment of calcium absorption from the gastrointestinal tract and its increased mobilization from the skeleton. In addition, they promote the development of arterial hypertension by increasing the sensitivity of blood vessels to the action of endogenous, vasopressor substances. Excessive ACTH secretion may also lead to skin discoloration and symptoms of androgenization in women and hyperaldosteronism.

  • Clinical picture and diagnosis

Patients with adrenal gland hyperthyroidism are characterized by a round face, obesity on the body and neck with slim limbs, pink skin stretch marks on the lower abdomen, hips, thighs and nipples. SickThey may complain of atrophy and weakness of the muscles, bone pain, high blood pressure and symptoms of androgenization, such as male pattern baldness, low voice tone, acne, menstrual disorders, hirsutism or enlargement of the clitoris (clitoromegaly). Psychotic symptoms are not uncommon. Laboratory tests of blood may show hypokalaemia, alkalosis and an increase in the number of red blood cells. Latent or overt diabetes mellitus is common. Hormone testing is used for diagnosis. The circadian rhythm of cortisolemia and the excretion of free cortisol in urine are determined. In addition, the dexamethasone suppression test is used, which allows you to differentiate whether we are dealing with adenoma or cancer of the adrenal gland, ectopic ACTH production, or microadenoma or pituitary adenoma. Instead of the dexamethasone suppression test, the CRF stimulation test is used to determine the cause of adrenal corticosteroid hyperfunction.

  • Diversification

Adrenal corticosteroid hyperthyroidism is differentiated from:

  • obesity coexisting with hirsutism, skin stretch marks, menstrual disorders and increased excretion of cortisol and its metabolites in the urine
  • Congenital Cortisol Resistance Syndrome
  • polycystic ovary syndrome
  • postalcoholic pseudo-Cushing syndrome
  • depression
  • Treatment

The treatment of choice is surgery to remove adenoma or cancer of the adrenal gland, microadenomas or pituitary adenomas that are the cause of hypercortisolemia. If there are contraindications for surgery, pituitary radiotherapy or steroidogenesis inhibitors such as trilostane, ketoconazole, mitotane or aminoglutethimide are used.

In case of ectopic excess production of CRF or ACTH by lung, pancreatic or gallbladder cancers, surgery is also indicated. Spironolactone or cyproterone acetate are used in the presence of symptoms of hyperteralocorticism and androgenization in women.

Mineralocorticoid hyperactivity of the adrenal glands

Mineralocorticoid hyperactivity of the adrenal glands, also known as hyperaldosteronism or excessive secretion of deoxycorticosteroids, may be primary or secondary. The primary causes of its occurrence include adenoma, cancer or adenomatous hyperplasia of the glomerular layer of the adrenal gland. Secondary causes of its development may be secondary aldosteronism in patients with renin-secreting tumor, renal ischemia, and hypertension.malignant or cardio-hepatocellular or renal-related edema or Bartter's syndrome.

  • Primary hyperaldosteronism

Primary aldosteronism is a disease syndrome resulting from the excessive secretion of aldosterone. It develops in the case of excessive secretion of aldosterone by adenoma (the so-called Conn's syndrome), cancer or in the presence of bilateral, less often unilateral, hyperplasia of the glomerular layer of the adrenal cortex (the so-called idiopathic hyperaldosteronism).

  • Pathophysiology

Excessive secretion of aldosterone contributes to the increased loss of potassium by the kidneys, and thus the development of hypokalemia and hypokalemic alkalosis. In addition, aldosterone directly and indirectly sensitizes blood vessels to the action of endogenous vasopressors such as adrenaline or noradrenaline, which promotes the development of arterial hypertension. It has also been shown that aldosterone is involved in vascular remodeling, leading to an increase in vascular resistance and thus an increase in blood pressure.

  • Clinical picture and diagnosis

Patients usually report high thirst, muscle weakness, paresthesia, tetany attacks, constipation and polyuria. Due to arterial hypertension, which is the main symptom, headaches and organ complications of hypertension may appear - kidney failure, blindness or stroke. With a significant potassium deficiency, there are life-threatening cardiac arrhythmias - including ventricular fibrillation.

Primary aldosteronism should be suspected especially in patients with hypokalaemia, drug-resistant hypertension and in patients with accidentally diagnosed tumor of the adrenal gland. Laboratory tests show hypernatraemia, hypokalaemia with hypokalaemic alkalosis, and hypomagnesaemia. Additionally, there is increased aldosteronaemia and aldosteronuria with normal cortisolemia and normal urinary 17-OH-corticosteroids, impaired acidification of urine and vasopressin-resistant polyuria. Possible carbohydrate intolerance.

  • Treatment

In the case of a unilateral adrenal cortex tumor, surgical removal is recommended after approximately 4 weeks of initial treatment with spironolactone. Bilateral adrenal hyperplasia is an indication for long-term use of antihypertensive drugs and aldosterone antagonists, such as spironolactone at a dose of 50-100 mg / day. Surgical treatment followed by chemotherapy is used in patients with aldosterone-producing cancer with possible metastases.Unfortunately, the prognosis in these cases is unfavorable. In any case, potassium supplementation should not be forgotten by administering KCL potassium chloride to patients, because it prevents the occurrence of life-threatening cardiac arrhythmias.

Androgenic or estrogenic hyperactivity of the adrenal glands

Overproduction of androgens by the adrenal glands may be due to the presence of a virilizing tumor, Cushing's disease or syndrome, and an inherited disorder of steroid biosynthesis. In the case of excessive estrogen production by the adrenal glands, it is characteristic of the presence of a feminizing tumor.

Virilizing tumor

This is a tumor in the reticular layer of the adrenal gland that overproduces androgens. These hormones can cause premature puberty in boys, girls' bisexual development, and virilization in women. Depending on whether the tumor is an adenoma or cancer, the symptoms reported by the patient may vary. In the presence of an adenoma, there may be increasing symptoms of defeminization, such as disturbances in the cyclicality of menstrual bleeding, atrophy of the mammary glands, redistribution of adipose tissue from the female to male type, and virilization symptoms such as male hirsutism, acne, seborrhea, alopecia and voice deepening. In the presence of cancer, in addition to the symptoms of virilization mentioned above, symptoms of hypercortisolism may also appear. They include, among others obesity of the body and neck, the presence of skin stretch marks in the lower abdomen, hips, thighs and nipples, muscle atrophy and weakness, hypertension, diabetes. Differential diagnosis includes:

  • inborn enzymatic defects of 21- and 11-hydroxylation and 3-β-hydroxysteroid dehydrogenase
  • polycystic ovary syndrome
  • androgen-producing testicular or ovarian tumors

When differentiating the disease, one should also bear in mind that Cushing's syndrome, caused by excessive production of ACTH, often manifests itself not only with hypercortisolism, but also with increased androgen biosynthesis. This is because ACTH stimulates the production of both glucocorticosteroids, mineralocorticosteroids and androgens. The clinical diagnosis is based on the results of hormonal tests, which show an increase in the concentration of androgens and their metabolites in the blood and an increase in their excretion in the urine. To locate the tumor, ultrasound, computed tomography and adrenal scintigraphy are performed. Treatment consists of surgical removal of the tumor.

Feminizing tumor

It's a tumor of the adrenal gland that overproduces estrogen. In order to establish the diagnosis, he statesincreased excretion of estrogens in the urine, feminization symptoms in men such as gynecomastia, hair loss or decreased libido, as well as menstrual disorders in women and an increase in the concentration of estrogen in the venous blood of the adrenal glands. To locate the tumor, ultrasound, computed tomography and adrenal scintigraphy are performed. Surgical removal of the tumor is used in the treatment.

Read also:

  • Pheochromocytoma - adrenal cancer
  • Congenital adrenal hyperplasia: causes, symptoms, treatment
  • Adrenal crisis (acute adrenal insufficiency): causes, symptoms and treatment

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