Adrenal Insufficiency

There are two adrenal glands that are located on top of each kidney.  The adrenal glands produce three types of hormones – glucocorticoids (cortisol), mineralocorticoids (aldosterone) and androgens (testosterone, DHEA, DHEA sulfate).  Cortisol is important in regulating blood sugar levels, helping the body respond to stress and infection and regulate fat metabolism.  Aldosterone helps regulate the body’s sodium and potassium levels, that in turn regulate blood volume and blood pressure.  Principal adrenal androgen is testosterone which is also produced in ovaries in women.  Most testosterone is produced in the testes.

Cortisol production by adrenal glands is regulated by pituitary hormone called ACTH, which in turn is regulated by a hypothalamic hormone called CRH (corticotrophin releasing hormone).  As the body’s cortisol level decreases, ACTH increases to stimulate more cortisol production and vice-versa.  In times of stress, ACTH is increased – which in turn increases needed cortisol.

Primary adrenal insufficiency (Addison’s Disease) occurs when the adrenal glands are unable to produce an appropriate amount of hormones – even though ACTH level increases.  This is felt to be due to an autoimmune process whereby the body produces antibodies against adrenal tissue that causes adrenal function to decrease.  Secondary adrenal insufficiency is due to an insufficient amount of ACTH being produced by the pituitary to stimulate the adrenal glands.  This can sometimes be caused by a pituitary tumor affecting ACTH only, or more often, affecting other pituitary hormones.

Symptoms of adrenal insufficiency can include fatigue, lightheadedness, darkening of the skin, weight loss, nausea, low blood pressure, salt craving and symptoms of low blood sugar.

Diagnosis of pituitary insufficiency is made by testing blood cortisol level – usually around 8:00 a.m..  A low morning cortisol level is consistent with adrenal insufficiency – further tests with ACTH levels help to differentiate between primary and secondary adrenal insufficiency.

Treatment of adrenal insufficiency consists of replacing missing adrenal hormones, i.e., cortisol, mineralocorticoids, and in some cases, androgens in women.  The principal glucocorticoid used to replace cortisol is prednisone or hydrocortisone.  Mineralocorticoid is replaced with oral synthetic mineralocorticoid fludrocortisone (florinef).  Androgen replacement is usually not required in men but  sometimes utilized in women.

Treatment with replacement hormone is usually life-long and needs to be monitored by a health care provider.  Fortunately, people lead normal, productive lives with normal longevity with appropriate treatment.

More information can be found on the following websites:
• The Hormone Foundation (
• National Adrenal Diseases Foundation (
• National Library of Medicine (

  • Thyroid and parathyroid ultrasound are available in our office, for your convenience.

• Office location: 477 Congress Street (the Time & Temperature Building), 5th floor, Portland, Maine 04101

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Thyroid and parathyroid ultrasound are available in our office, for your convenience.
David R. Hotelling, MD, FACE, is on the medical staff at Maine Medical Center and is a consulting staff member at Mercy Hospital. Dr. Hotelling is board-certified and completed a fellowship in endocrinology at Beth Israel Hospital in Boston, a Harvard affiliate.