Adrenal Insufficiency

Adrenal Insufficiency (Addison’s Disease) – Overview and Guide

Introduction to Adrenal Insufficiency

Adrenal insufficiency is a condition where the adrenal glands do not produce enough essential hormones, primarily cortisol (and in some cases aldosterone). There are two main forms: primary adrenal insufficiency, known as Addison’s disease, and secondary adrenal insufficiency. In Addison’s disease, the adrenal glands themselves are damaged or diseased and cannot meet the body’s hormone needs. This often happens due to an autoimmune attack on the adrenal cortex (the gland’s outer layer) that destroys hormone-producing cells. In contrast, secondary adrenal insufficiency occurs when the pituitary gland (a gland at the base of the brain) fails to signal them properly with a hormone called ACTH. Without enough ACTH, the adrenals don’t get the “message” to make cortisol. Secondary adrenal insufficiency can develop, for example, after long-term use of corticosteroid medications that suppress the pituitary, or from pituitary tumors or surgery.

The adrenal glands themselves are small, triangular organs that sit on top of each kidney. They consist of an outer cortex and inner medulla. The cortex makes vital steroid hormones: glucocorticoids (like cortisol) which help regulate metabolism, stress response, and immune function, and mineralocorticoids (like aldosterone) which regulate blood pressure and salt balance. (The adrenals also produce small amounts of sex hormones such as DHEA.) In Addison’s disease, the adrenal cortex is unable to produce enough cortisol (and often aldosterone), leading to the symptoms and health issues described below. Secondary adrenal insufficiency mainly involves cortisol deficiency; because the adrenal gland itself is intact, aldosterone levels are usually normal in secondary insufficiency, so dehydration and salt-balance issues tend to be less severe than in Addison’s. Regardless of type, adrenal insufficiency can significantly impact a person’s health and energy if not recognized and treated.

Symptoms and Signs of Adrenal Insufficiency

General symptoms: Adrenal insufficiency often develops gradually, and early signs can be subtle or mistaken for other illnesses. Common symptoms include:

• Chronic fatigue and weakness: An ongoing, worsening tiredness that doesn’t improve with rest.
• Loss of appetite and weight loss: Unintentional weight loss often accompanies Addison’s.
• Low blood pressure (hypotension): Especially a drop in blood pressure upon standing, causing dizziness or fainting (orthostatic hypotension).
• Skin changes: Hyperpigmentation, a darkening of the skin, especially in primary adrenal insufficiency (Addison’s). This often shows up in skin folds, scars, joints like elbows/knuckles, or mucous membranes (gums) as patchy brown or bronze discoloration. (Notably, this bronzing does not occur in secondary adrenal insufficiency, since that form doesn’t cause the high ACTH levels that trigger pigment changes.) Some people with Addison’s also develop patches of vitiligo (light skin areas) alongside darker patches.
• Gastrointestinal issues: Nausea, vomiting, abdominal pain, and occasionally diarrhea are common. Salt craving is another hallmark sign – craving very salty foods due to the body’s need for sodium.
• Muscle and joint pains: General muscle aches, cramps, or joint pain can occur.
• Low blood sugar (hypoglycemia): People with adrenal insufficiency may have episodes of low blood sugar, causing shakiness or sweating, particularly in secondary adrenal insufficiency.
• Mood and energy changes: Depression, irritability, and a loss of interest in activities or a drop in libido (especially in women) can happen as hormone levels fall. Women with Addison’s may notice menstrual irregularities or loss of pubic/axillary hair due to low levels of adrenal androgens.

Symptom differences between primary and secondary: Both types share many of the above symptoms (fatigue, weakness, appetite loss, etc.). However, certain features are more pronounced in Addison’s disease (primary adrenal insufficiency). As noted, darkening of the skin (hyperpigmentation) is a key sign of Addison’s and does not occur in secondary adrenal insufficiency. Patients with Addison’s are also more prone to severe dehydration, low blood pressure, and salt cravings because they often lack aldosterone, which helps retain salt and water. By contrast, someone with secondary adrenal insufficiency (pituitary-related) usually produces normal aldosterone, so they may have milder blood pressure issues and less salt craving; on the other hand, they might experience low blood sugar more frequently. Recognizing these differences can help doctors distinguish the cause of adrenal insufficiency.

Severity – Addisonian crisis: If adrenal insufficiency is untreated or stressed by factors like infection, injury, or surgery, a life-threatening episode called an adrenal crisis (Addisonian crisis) can occur. In an adrenal crisis, symptoms escalate rapidly and may include: severe weakness, confusion, intense abdominal, lower back or leg pain, vomiting and diarrhea, very low blood pressure (leading to shock), and loss of consciousness. An adrenal crisis is a medical emergency – without prompt treatment (with injectable cortisol and IV fluids), it can be fatal. Important: If you know you have adrenal insufficiency, or suspect it and have sudden severe symptoms as described, seek emergency medical care immediately.

Diagnosis: How Adrenal Insufficiency Is Detected

Diagnosing adrenal insufficiency involves a combination of clinical evaluation and laboratory tests. Because early symptoms can be nonspecific, doctors will first review your medical history and symptoms to see if adrenal insufficiency is a possibility. If it is suspected, the next steps typically include:

• Blood tests for cortisol and ACTH: Cortisol is usually highest in the early morning, so an 8 AM blood cortisol level is often measured. Low cortisol, especially with symptoms present, raises concern for adrenal insufficiency. At the same time, a blood level of adrenocorticotropic hormone (ACTH) can be checked. In primary adrenal insufficiency (Addison’s), cortisol will be low and ACTH is typically high (because the pituitary is trying, unsuccessfully, to stimulate the adrenals). In secondary adrenal insufficiency, both cortisol and ACTH are low or inappropriately normal (since the pituitary is not producing enough ACTH). Doctors may also check levels of electrolytes (sodium and potassium), as Addison’s often causes low sodium and high potassium due to aldosterone loss. Another blood test sometimes done is for 21-hydroxylase antibodies, which can confirm an autoimmune cause of Addison’s.
• ACTH stimulation test: This is a definitive lab test for adrenal insufficiency. In this test, a synthetic ACTH hormone is given by injection, and blood cortisol is measured before and after the injection. In healthy individuals, cortisol levels should rise in response to ACTH. In Addison’s disease or long-standing secondary adrenal insufficiency, the adrenal glands will fail to produce a higher level of cortisol after the ACTH shot. Little or no increase in cortisol confirms adrenal insufficiency. (For someone with a recent-onset secondary adrenal insufficiency, the test can sometimes appear normal early on, because the adrenal glands haven’t yet shrunken from disuse.)
• Additional stimulation tests: If the ACTH test is inconclusive or a central (pituitary) cause is suspected, other tests like the insulin tolerance test (ITT) or a CRH stimulation test may be used. In an ITT, the patient receives insulin to induce a controlled drop in blood sugar, which should stress the body and trigger cortisol release. Lack of a cortisol rise during severe hypoglycemia suggests secondary adrenal insufficiency due to pituitary dysfunction. A CRH stimulation test (using corticotropin-releasing hormone) can help distinguish between a pituitary (secondary) and hypothalamic (tertiary) cause by measuring how the pituitary responds in releasing ACTH. These tests are more specialized and done under close medical supervision.
• Urine and saliva tests: Besides blood tests, adrenal function can be assessed through urine and saliva in some cases. A 24-hour urine cortisol test measures the total free cortisol your body releases in a day; in untreated adrenal insufficiency, this would be low (this test is more often used to diagnose high cortisol, Cushing’s, but may sometimes be utilized to confirm low output). Salivary cortisol tests (often done at multiple times in one day, such as morning, afternoon, evening, and bedtime) are used to examine the diurnal rhythm of cortisol. In adrenal insufficiency, the overall levels in saliva would be low across the day. Saliva tests are also commonly marketed in evaluating “adrenal fatigue” (see further below), though in proven adrenal insufficiency the deficit is usually obvious on standard tests.
• Adrenal and pituitary imaging: Once lab tests confirm adrenal insufficiency, doctors may do imaging to find the cause. An abdominal CT scan can check the size and appearance of the adrenal glands – for example, small shrunken adrenals suggest long-standing autoimmune Addison’s, while enlarged or calcified adrenals might point to other causes like infection (TB) or hemorrhage. If secondary adrenal insufficiency is diagnosed, an MRI of the brain may be ordered to look at the pituitary gland for tumors or other abnormalities.

In summary, the diagnosis is usually confirmed by demonstrating low cortisol that fails to respond to stimulation, and then additional tests pinpoint whether the problem lies in the adrenals or the pituitary. If you suspect you have adrenal insufficiency, it’s important to see a healthcare provider for proper testing – the above evaluations should be conducted by medical professionals. Self-diagnosis via over-the-counter adrenal “function” tests is not reliable.

The “Adrenal Fatigue” Concept – Myth vs. Reality

You may have heard the term “adrenal fatigue” in blogs, social media, or alternative health circles. This concept proposes that chronic stress can overwork the adrenal glands to the point that they “burn out” and fail to produce sufficient hormones, causing symptoms like constant fatigue, brain fog, body aches, sleep disturbances, low mood, and salt or sugar cravings. It’s important to know that adrenal fatigue is not an established medical diagnosis. Major endocrinology organizations and medical experts do not recognize adrenal fatigue as a real condition, because there is no solid scientific evidence that healthy adrenal glands become exhausted in this way.

The symptoms attributed to “adrenal fatigue” are very nonspecific – meaning they can have many possible causes. When patients feel persistently unwell and standard tests are normal, it’s understandably frustrating, and adrenal fatigue is an appealing explanation. However, research has found that people with these burnout-like symptoms usually do not have abnormal cortisol levels on sensitive tests. In one review of studies, the majority showed no difference in salivary cortisol patterns between individuals reporting “adrenal fatigue” symptoms and healthy individuals. In other words, while stress can indeed affect our hormonal rhythms, it does not typically lead to true cortisol deficiency unless the adrenal glands are significantly damaged or the brain’s regulation is impaired – which would be the medical disorders of adrenal insufficiency we discussed above, not a mild “fatigue” state.

That said, the conversation around adrenal fatigue often highlights real health issues – chronic stress, inadequate rest, and symptoms that are not being explained. If you are feeling constant fatigue, low energy, poor sleep, and mood changes, it’s crucial to see a healthcare provider. Those symptoms merit a thorough evaluation to check for verified conditions such as adrenal insufficiency (Addison’s disease), thyroid disorders, anemia, sleep apnea, chronic infections, depression, etc., rather than assuming they must be “adrenal fatigue.” Simply attributing serious symptoms to a vague adrenal label can delay finding the true cause and effective treatment. In summary, “adrenal fatigue” is a misleading term – while prolonged stress can make you feel awful, your adrenal glands are usually still producing hormones appropriately. It’s better to talk to a doctor about your symptoms, manage stress, and address any real medical problems.

Treatment and Management of Adrenal Insufficiency

Adrenal insufficiency is treatable, and people with this condition can lead healthy lives – but it requires lifelong management in most cases. The core approach is to replace the hormones that the adrenal glands can’t make and to address the underlying cause when possible.

Hormone replacement therapy: The mainstay treatment for Addison’s disease (primary adrenal insufficiency) is daily corticosteroid medication to replace cortisol. Typically, a form of hydrocortisone (which is identical to cortisol) is given orally one to three times a day to mimic the natural rhythm of cortisol production. Some patients take other glucocorticoids like prednisone or dexamethasone – the choice and dosing depend on individual needs. In primary adrenal insufficiency, you will also need a replacement for aldosterone. The medication fludrocortisone acetate is a synthetic mineralocorticoid taken once daily that helps retain salt and keep blood pressure normal. People with secondary adrenal insufficiency (pituitary cause) usually do not need fludrocortisone, because their aldosterone production remains sufficient; they typically need only cortisol replacement (since ACTH is low).

Dosing and monitoring: The doses of these medications are adjusted to the lowest amount that stops symptoms and normalizes labs, to avoid overtreatment. It’s important to take your steroid medication every day as prescribed, without missing doses. You will work with your doctor to find the right dose – too little can leave you fatigued, while too much over time could cause side effects (like weight gain, high blood sugar, or bone thinning). Regular follow-ups and blood tests help ensure you’re on track. Most people start to feel much better once on proper replacement therapy, though it may take a few months to fully regain energy.

Stress dosing: One of the most critical aspects of managing adrenal insufficiency is knowing how to adjust your medication during physical stress. Under normal circumstances, healthy adrenal glands pump out extra cortisol when you’re sick, injured, or undergoing surgery. If you have adrenal insufficiency, you must replicate this by increasing your dose in such situations. For example, if you get a fever or a bad flu, you might double or triple your oral cortisol dose for a couple of days (always follow your endocrinologist’s instructions on when and how to do this). For any major stress like a serious injury, vomiting illness (when you can’t keep pills down), or surgical procedure, you will need an injection of hydrocortisone to avoid an adrenal crisis. Patients are often taught to give themselves an emergency cortisol injection (or a family member is taught) if severe symptoms or injury occurs. Always inform healthcare providers (surgeons, ER doctors, etc.) that you have adrenal insufficiency so they can administer IV steroids in emergencies.

Lifestyle and supportive measures: There are several things individuals with adrenal insufficiency should do in daily life to stay safe and healthy:

• Medical alert identification: It’s strongly recommended to wear a medical alert bracelet or necklace stating “Adrenal Insufficiency – takes hydrocortisone,” etc. Carrying a wallet card with details is useful as well. In an emergency, this alerts responders that you need steroids urgently.
• Emergency kit: Keep an emergency hydrocortisone injection kit on hand (e.g., Solu-Cortef vial and syringes) if prescribed. Ensure that you and someone close to you know how to use it in case of an adrenal crisis. This can be a lifesaver – for instance, if you have vomiting and can’t take oral pills, an injection can treat you while awaiting medical care.
• Extra medication supply: Always have a few days’ extra medication with you, especially when traveling. Missing even one day’s dose can be risky. It’s wise to keep backup pills at work, in your bag, or when away from home.
• Diet and salt: Unless your doctor advises otherwise, liberal salt intake is often encouraged for Addison’s patients (since you lack aldosterone). You may actually crave salty foods – and listening to your body in this case is good. During hot weather, heavy exercise (sweating), or episodes of diarrhea, extra salt and fluids are important to prevent dehydration.
• Routine and stress management: Maintaining a regular medication schedule and a healthy lifestyle (balanced diet, adequate sleep, managing stress) will help you feel your best. Though life with Addison’s is normal for most, you might notice you have a bit less stress tolerance than others – so don’t hesitate to rest and adjust activities as needed. Learn to recognize early signs that you might need a stress dose (for example, if you start feeling very weak or nauseated when ill). Always err on the side of caution and contact your healthcare provider if unsure.

DHEA supplementation: In some cases, doctors might consider replacing DHEA (an adrenal androgen) in Addison’s disease. Women in particular may benefit if they have low energy, mood changes, or loss of libido despite optimal cortisol/aldosterone replacement. Some studies showed improved well-being when women with adrenal insufficiency took low-dose DHEA. This is not standard therapy for everyone, but it is an option. (DHEA is available over the counter in certain countries or via prescription.) For example, in the UK, DHEA is not provided by the NHS but patients can obtain it privately; discussion with an endocrinologist is advised to determine proper dosing and need. If you think DHEA might help, talk to your doctor – they can check your DHEA-S levels and see if a trial of therapy is appropriate.

Overall, treatment is about hormone balance – replacing what’s missing in a physiologic way. With conscientious management, most people with adrenal insufficiency recover their strength and can do all the activities they love. It requires learning about the condition and being prepared, but many patients become very adept at self-care (for example, increasing their dose during a head cold and then returning to maintenance dose). Never adjust your medications without medical advice, but do have a clear plan from your healthcare team on how to handle illnesses or emergencies.

Prognosis and Long-Term Outlook

Living with adrenal insufficiency is a lifelong commitment to daily medication, but when properly treated, the outlook is generally excellent. Prognosis is good: individuals on correct replacement therapy can expect to live normal, active lives. People have climbed mountains, run marathons, had healthy pregnancies, and pursued any number of careers while managing Addison’s disease – the key is adherence to treatment and good medical follow-up.

Once on treatment, many symptoms of adrenal insufficiency improve dramatically (energy returns, appetite and weight stabilize, blood pressure normalizes, etc.). You will need regular check-ins with your doctor (often an endocrinologist) to ensure your dosing is optimal and to monitor for any associated conditions. It’s important to carry or wear your medical ID and have an emergency plan, as discussed, but outside of those precautions, you should be able to do most things anyone else can.

There are a few long-term considerations to keep in mind:

• Other autoimmune diseases: If your Addison’s is autoimmune (which is most common), you have a higher chance of developing other autoimmune disorders over time (such as thyroid disease, type 1 diabetes, or pernicious anemia). Up to 50% of people with Addison’s may develop another autoimmune condition in their lifetime. For this reason, your doctor might periodically screen for symptoms or signs of related conditions. Any new symptoms should be reported – for example, if you develop fatigue that doesn’t resolve with proper meds, they might check your thyroid function. Early detection of any associated illness helps keep you feeling well.
• Medication balance: As mentioned, avoid over- or under-replacement. Taking too little cortisol will result in ongoing fatigue and risk of crisis, while taking too much for too long can lead to Cushingoid effects (weight gain, high blood sugar, osteoporosis, etc.). Similarly, fludrocortisone dose is tuned to keep your blood pressure and electrolytes in range; excessive doses could raise blood pressure or cause swelling. Your healthcare team will typically monitor your blood pressure, electrolytes, weight, and symptoms and adjust doses accordingly. Never stop your glucocorticoid suddenly, and never skip fludrocortisone if prescribed, as that could quickly lead to serious illness.
• Quality of life: Many patients report that once they get into a routine with their medications, they feel quite normal. It can be challenging at first to accept a chronic condition – but note that Addison’s treatment today is much advanced from decades past. If you take care of yourself and pay attention to your body’s signals, your long-term health should be on track. Support groups (online or local) can also be a great resource for tips and encouragement from others living with adrenal insufficiency.

Modern medical advances and patient education have made adrenal insufficiency a very manageable condition. The main risk to be aware of is adrenal crisis, which is preventable with proper stress dosing and emergency preparedness. Make sure at least one or two close contacts know about your condition and what to do if you were to have severe symptoms (i.e., give the emergency injection and call an ambulance). Regular follow-up ensures your treatment is optimized. With these measures, the long-term outlook is that you can live a full, healthy life – Addison’s should not stop you from pursuing your goals.

When to Seek Medical Evaluation

Because adrenal insufficiency symptoms can be gradual and vague, it’s important to have a low threshold for consulting a healthcare provider if you suspect something is wrong. See a doctor if you experience a combination of the following persistent symptoms: profound fatigue that doesn’t improve, ongoing muscle weakness, loss of appetite or unexplained weight loss, episodes of dizziness or fainting upon standing, abdominal pain with nausea, or areas of unusual skin darkening. Craving salt constantly or having cravings accompanied by fatigue and low blood pressure readings should also prompt evaluation. These signs don’t always mean Addison’s disease – they could indicate other conditions – but they warrant a thorough check-up, which should include at least a cortisol level test. Early diagnosis of adrenal insufficiency is crucial to avoid dangerous complications.

If you are on long-term corticosteroid treatment (for example, for asthma, arthritis, or other chronic conditions) and are tapering off the medication, stay in close contact with your doctor. If you develop severe fatigue, weakness, pain, or nausea during a steroid taper or after stopping, seek medical advice right away – the adrenal glands can take time to “wake up” after long steroid use, and you might need testing to ensure you haven’t developed a temporary adrenal insufficiency.

Emergencies: If you know you have adrenal insufficiency, you should seek immediate medical care or call emergency services if you have symptoms of an adrenal crisis: severe weakness, confusion, severe abdominal or back pain, vomiting, dehydration, or fainting. Administer your emergency injection (if available) and then get to a hospital. If you suspect someone is in adrenal crisis (for instance, they have Addison’s disease and can’t respond appropriately), this is a medical emergency – call for help without delay.

Finally, trust your instincts. Adrenal insufficiency can be hard to diagnose, but you know your body best. If you feel that something isn’t right – for example, you’re unusually tired all the time, tan looking without sun exposure, and just not yourself – don’t hesitate to request a medical evaluation. A few simple lab tests can either put your mind at ease or point toward a treatable explanation. It’s always better to check early than to suffer in silence or wait for a crisis to occur.

Summary: Adrenal insufficiency (Addison’s disease and secondary adrenal insufficiency) is a serious but treatable condition. Be aware of the symptoms and listen to your body. With proper diagnosis, hormone replacement, and self-care, individuals with adrenal insufficiency can thrive. If you suspect you have this condition or you have concerning symptoms, reach out to a healthcare provider for testing – and if you have been diagnosed, make sure to stay on top of your treatment plan and follow your doctor’s guidance. Early recognition and ongoing management are the keys to living well with adrenal insufficiency.