Adrenal Frequently Asked Questions

What is the adrenal gland?

The adrenal glands are two small glands that are several centimeters in length (about the size of your thumb), which sit above each kidney in the back of the abdomen. The adrenal glands are responsible for making hormones that control blood pressure and respond to physical stress (fight or flight response), and still others that make us male and female.

Which hormones do the adrenal glands make?

The adrenal gland makes a number of different hormones. The outer layer – cortex – produces mineralocorticoids (e.g. aldosterone), glucocorticoids (e.g. cortisol), and sex steroids (e.g. testosterone and progesterone). The inner layer – medulla – produces catecholamines (e.g. epinephrine, also known as adrenaline, and norepinephrine, also known as noradrenaline).

· Mineralocorticoids – help regulate blood pressure and potassium

· Glucocorticoids – help regulate blood pressure and adjust the body’s response to stress

· Sex steroids – help give us the features that make us men or women

· Catecholamines – help the body respond to stress by controlling our “fight or flight” response, and affect blood pressure

What is the function of aldosterone?

Aldosterone affects sodium, potassium, total fluid in the body, and blood pressure. Aldosterone causes the kidneys to hold onto more sodium, which leads to more water staying in the body. The more fluid the body holds onto, the higher the blood pressure may become. Potassium may decrease as the amount of aldosterone increases. Aldosterone also directly affects the heart and blood vessels.

What is cortisol?

Cortisol, a steroid, has three main functions. It causes the liver to produce sugar and causes break down of muscle and fat to create this sugar. Cortisol also helps the body regulate its response to stress. Lastly, cortisol decreases inflammation and decreases the immune system response. Excess steroids can lead to Cushing’s syndrome, obesity, diabetes, high blood pressure, weak muscles, characteristic bodily changes, and brittle bones.

What are the side effects of excessive cortisol?

Too much cortisol, known as hypercortisolism, can have unwanted side effects in the form of obesity, diabetes, muscle weakness and breakdown, change in distribution of fat in the body (skinny arms and legs, big belly), thin skin, striae (purple lines on the abdomen similar to stretch marks), and brittle bones leading to osteoporosis and fractures. These outward signs of excess cortisol are in total called Cushing syndrome. Depression, memory problems, and cataracts can also result from excess cortisol. Growth and puberty can be interrupted in children. Females can have difficulty getting pregnant. People with too much cortisol are also at increased risk for infection and may not heal wounds well.

What can I do to lower my cortisol level?

Depending on the cause of your excess of cortisol, medical or surgical treatment may be appropriate. The most common cause of too much cortisol is taking medications that contain cortisol. These medicines are usually prescribed for inflammatory problems (e.g. asthma, arthritis), skin disorders (topical steroids/creams), or auto-immune problems (e.g. lupus). The best way to lower your cortisol level in these cases is to work closely with your doctor to only take glucocorticoid-containing medicines when absolutely necessary, take the minimum amount necessary, and to switch, when possible, to non-steroid containing medications that can treat your condition.

Chronic stress, alcohol and caffeine use are all things that can increase your cortisol level. Regular exercise, healthy attitudes and approaches to dealing with stress, and moderation of alcohol and caffeine intake can all lower your cortisol level.

If surgery is required, removal of a tumor in the pituitary gland, removal of an ACTH producing tumor elsewhere in the body, or removal of one and sometimes both of the adrenal glands can take care of excess cortisol levels.

What happens when the adrenal glands malfunction?

Adrenal glands that malfunction can either produce too little or too much hormone. Too few hormones (adrenal insufficiency, also known as Addison’s disease) can be fatal and patients must take medications to supplement their low hormone levels. Too much hormone can lead to a variety of effects depending on which hormone is being over-produced. Too much aldosterone can lead to high blood pressure and dangerously low potassium levels, strokes, and heart attacks. Too much cortisol can lead to Cushing’s syndrome. Too much testosterone can lead to females developing male characteristics (e.g. deeper voice, increased body hair). Too much adrenaline can lead to high blood pressure, a heart attack, or stroke.

For more information, see the following sections:
Primary hyperaldosteronism (Conn’s syndrome or aldosterone-producing adrenal tumor)
Cushing’s syndrome (cortisol-producing adrenal tumor)
Pheochromocytoma (adrenaline-producing adrenal tumor)
Sex hormone-producing adrenal tumor

Does my small adrenal tumor need to be removed?

With the increasing use of CT scans and MRI, doctors are more likely these days to find small adrenal tumors (generally less than four centimeters in size) that they otherwise would not have known about (incidentaloma). As patients get older, they are more likely to have one of these small adrenal tumors. Most small adrenal tumors, unless they have suspicious imaging features, do not need to be removed. Your doctor should also obtain blood and/or urine tests to make sure the tumor is not producing excess hormones. You should also receive age-appropriate health screening to ensure that a small adrenal tumor is not a cancer that has spread from somewhere else (metastasis). Finally, small adrenal tumors that grow significantly over a short period of time may need to be removed. A repeat CT scan or MRI should be obtained six to twelve months after your first scan to make sure the tumor is not getting bigger.

What should I expect after adrenal surgery?

After laparoscopic adrenalectomy, many patients may be discharged from the hospital as early as the day after surgery. After open adrenalectomy, the hospital stay is longer and averages 4-5 days. The ability to eat may be delayed for several days after open adrenalectomy until the bowels start moving again. Patients may shower 48 hours after surgery. Heavy lifting or vigorous activity should be avoided for at least 4 weeks to decrease the chance of wound complications and formation of a hernia, but patients will be encouraged to get up and walk as soon as possible. The overall recovery time for open adrenalectomy is significantly longer than for laparoscopic surgery.

What type of anesthesia will I need for my adrenal surgery?

All adrenalectomies are performed under general anesthesia. Some patients who undergo an open adrenalectomy may have an epidural placed which helps decrease pain after surgery. For those undergoing laparoscopic surgery, local anesthetic (numbing medicine) is usually injected at the incision sites to help with pain. Often, a pain pump (PCA – patient controlled analgesia) is provided to the patient for the first couple of days so they may administer their own pain medication as needed.

How can I find an experienced adrenal surgeon?

Click on the “Find a Surgeon” tab on the AAES Patient Education Site. In general, a surgeon should do more than 20 adrenal operations a year to be considered an expert. Surgeons with experience operating on adrenal cancer are few, and patients with possible adrenal cancer should research this carefully prior to surgery with the help of their endocrinologist or primary care physician. Patients should not be shy or embarrassed to ask how many adrenal operations a surgeon has done and what their complication rate is. Check with your endocrinologist or primary care physician for recommendations of an experienced adrenal surgeon in your area or around the country, or research a dedicated endocrine surgeon in your area through the “Find A Surgeon” tab on the patient education site.

Will I need a drain after my adrenal surgery?

Patients rarely require drains after adrenal surgery; however, if the surgeon thinks it is necessary, an abdominal drain will be placed. Drains are more often required after open adrenalectomy than after laparoscopic adrenalectomy. Drains are relatively easy to take care of, and the output is recorded on a daily basis. Once the output decreases to a certain level, the drain will be removed. Removal of the drain is not particularly painful. In general, the drain will be removed several days after surgery.

What are the most common complications that may occur after adrenal surgery?

Pneumonia, wound infections, bleeding, need for blood transfusions, and blood clots (deep vein thrombosis or pulmonary embolus) are rare, but may occur after adrenal surgery. Damage to other nearby organs may occur, but this is also rare. Adrenal insufficiency is a potentially life-threatening complication that may occur in patients who had surgery for Cushing’s syndrome or Cushing’s disease, or who had both adrenal glands removed if not enough cortisol is produced for the body after surgery. Symptoms of this condition include feeling generally unwell, nausea, vomiting, and confusion. Patients may need steroid medications. It is recommended that patients obtain and wear a medical alert bracelet or other device to alert medical personnel that an adrenal gland has been removed and they may require steroids as a lifesaving measure.

How long does the surgery to remove the adrenals take?

The length of time spent in surgery for adrenalectomy can vary greatly. On average, both laparoscopic and open operations last approximately 1.5-3 hours; however, the procedure can be shorter or longer depending on a variety of factors. Your surgeon will discuss this with you at the time of your appointment and provide you with a more accurate estimate based on the specifics of your case.