What is adrenal insufficiency?

Adrenal insufficiency and Addison disease are hormonal or endocrine disorders caused by the body
not producing enough of the adrenal hormones cortisol and aldosterone. This typically occurs when
there is a malfunction in the system that maintains a close and timely balance of these hormones.
This balance is achieved through a system of signaling and a feedback system. Signals sent and
received among the hypothalamus in the brain, the pituitary gland in the brain, and the adrenal
glands (located on top of each kidney) regulate adrenal hormone production.
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The adrenal glands are multi-layered:

The outer layer produces aldosterone, a salt-balancing hormone that has effects on blood
pressure.
The middle layer produces cortisol, a hormone with effects on blood sugar, blood pressure
and inflammatory responses.
The deepest layer produces hormones called androgens, which have effects on growth of
sexual hair and acne, for example.
Normally, cortisol is produced and released by the adrenal cortex. Production of the hormone is
regulated by the hypothalamus and the pituitary gland. When the blood cortisol level falls, the
hypothalamus releases corticotropin-releasing hormone (CRH), which directs the pituitary gland to
produce ACTH (adrenocorticotropic hormone). ACTH stimulates the adrenal glands to produce and
release cortisol. In order for appropriate amounts of cortisol to be made, the hypothalamus and both
the pituitary and adrenal glands must be functioning properly.
Without enough cortisol or aldosterone, people become weak and dehydrated, unable to maintain an
adequate blood pressure or to respond properly to physical stress. Among its many roles, cortisol
affects the metabolism of carbohydrates, proteins, and fats, affects glucose levels in the blood, acts
as an anti-inflammatory agent, and helps the body react to stress such as infection or trauma.
Aldosterone is produced by the adrenal cortex and manages the salt and potassium balance in the
blood.
There are two different types of adrenal insufficiency and they depend on whether pituitary gland or
adrenal dysfunction underlies hormone deficiencies:
Primary adrenal insufficiency (Addison disease)caused by underactive or damaged
adrenal glands, which affect cortisol and aldosterone levels in the blood.
Addison disease is relatively rare. It affects about 1 person per 100,000 in the U.S. It is
found in people of all ages and affects both males and females equally. Symptoms of
insufficiency may not emerge until about 80% to 90% of the adrenal cortex has been
destroyed.
In the U.S., the most common cause (about 75%) of primary adrenal insufficiency in adults
is an autoimmune process. It may occur with other autoimmune conditions that affect other
glands, such as the thyroid. The rest of the time, Addison disease is due to other causes, such
as tuberculosis, a common cause in areas of the world where tuberculosis is more prevalent,
other chronic infections, especially fungal infections, bleeding into the adrenal glands
(hemorrhage) and the spread of cancer into the adrenal glands. Rarely, it may be due to a
genetic abnormality of the adrenal glands.
In children, about 70% of cases are caused by a congenital disease termed congenital
adrenal hyperplasia (CAH), while 30% of the time adrenal damage is due to autoimmune
disease, the inherited disease adrenoleukodystrophy, or less common causes.
Secondary adrenal insufficiencya decrease in the production of the pituitary hormone
ACTH (adrenocorticotropic hormone) is at the root of secondary adrenal insufficiency.
ACTH is a pituitary messenger; it tells the adrenal cortex to produce cortisol. If there is
insufficient ACTH, due to pituitary damage, a pituitary tumor, or some other cause, then
cortisol production is not stimulated. Secondary adrenal insufficiency can also arise when
corticosteroid therapy (such as prednisone, which may be given to relieve inflammation in
conditions such as rheumatoid arthritis or high dose inhaled steroids, which may be given to
treat asthma ) is abruptly halted. These treatments suppress natural cortisol production and it
can take several weeks or months for normal production to resume.