Primary vs Secondary Adrenal Insufficiency
Primary Adrenal Insufficiency most often refers to Addison’s disease, whereas Secondary Adrenal Insufficiency most often refers to hypopituitary. Adrenal insufficiency itself simply means the failure to produce enough cortisol.
Primary and Secondary are NOT what many hypothyroid patients get that causes their low cortisol. Instead, please study the last chapter in the STTM II book to understand why hypo patients can find themselves with low cortisol.
1) What is the difference between the terms Primary and Secondary Adrenal Insufficiency?
From http://endocrine.niddk.nih.gov/pubs/addison/addison.htm: “Failure to produce adequate levels of cortisol can occur for different reasons. The problem may be due to a disorder of the adrenal glands themselves (primary adrenal insufficiency like Addison’s Disease) or to inadequate secretion of ACTH by the pituitary gland (secondary adrenal insufficiency like Hypopituitary).” tm
ACTH is an abbreviation for adrenocorticotropic hormone, produced by the pituitary gland, which stimulates the adrenal glands to produce cortisone. As you know, the pituitary also controls the amount of thyroid hormones by secreting Thyroid Stimulating Hormone (TSH). It is a similar concept.
For most, there is no cure for Secondary Adrenal Insufficiency; the missing hormones will need to be taken for life.
2) What causes Primary Adrenal Insufficiency like Addison’s?
The most common reason today is an autoimmune attack on the adrenal gland – which can be determined by blood test. In underdeveloped countries, tuberculosis remains a cause of Addison’s disease. Those situations will gradually destroy the adrenal glands.
There can be lesser degrees of insufficiency of the adrenal glands – and you could say that if the problem is not a progressive destruction of the gland, it is not Addisons. In Dr Gerald Poesnecker’s book, Chronic Fatigue Unmasked, he talks about simple heredity – some people are born with weak adrenals. If you do an internet search using the terms “adrenal enzyme deficiency” you will discover that some people are born with genetic issues that affect the body’s ability to make cortisol (and sometimes aldosterone). This is not as rare as you might think: “The estimated prevalence is 1 case per 60 individuals in the general population.” http://emedicine.medscape.com/
These can be rather permanent – something to keep in mind if you have been trying to restore full adrenal function by taking supplements. The adrenal glands can also be affected by viral and fungal infections. Dr Hans Selye’s early work demonstrated how stress can affect the adrenal glands – and many doctors believe that this type of adrenal fatigue can be reversed.
3) What causes Secondary Adrenal Insufficiency like hypopituitary?
Low functioning of the pituitary (hypo-pituitary) can be caused by an impact to the head, a tumor on the pituitary gland, antibodies to the pituitary (no lab test for this), or simply being born that way. In the books by Dr’s Jefferies and Teitelbaum, they discuss severe illness such as flu affecting the pituitary–adrenal hormone production. Some doctors believe that Epstein Barr Virus and other viral infections can affect the pituitary gland, resulting in lowered request for cortisol.
4) How do I test for Secondary Adrenal Insufficiency like hypopituitary?
With Secondary AI, the amount of ACTH in the blood is below normal. The pituitary should be asking for more cortisol, but it isn’t. A “serum ACTH” test will help answer this question, and it should be done in the early morning. This is different than someone with Primary Adrenal Insufficiency who would have high levels of ACTH in the blood, but low levels of cortisol because the adrenals were failing.
Your Dr. may want to just check serum ACTH and Serum cortisol levels before ordering more tests – or the lab could draw blood for those tests and then proceed immediately to an ACTH stimulation test, where artificial ACTH is injected, and serum cortisol levels are measured from blood samples drawn after 30 and 60 minutes. If the amount of cortisol produced by the adrenals responds adequately to the injection, you will be able to learn if the problem is with the adrenal gland itself, or the pituitary.
Sometimes both can be a source of trouble – for example the low pituitary output of ACTH has gone on so long that the adrenal gland has atrophied. And there can be shades of gray with the pituitary production of ACTH. Hypo-pituitary problems are not always a simple “black and white” lab result. Dr Jefferies says “Mild secondary adrenocortical deficiency is characterized by a baseline plasma cortisol level either low or in the low normal range, but with a normal response to Cortrosyn stimulation.” (Cortrosyn is a synthetic acth that is injected to determine the adrenal gland’s response to stimulation).
Remember – you cannot test for cortisol or ACTH if you are already taking HC.
Another way to discern hypopituitary is to test other messenger hormones released by the pituitary like FSH, LH, GH, etc. If they are low, it can mean hypopituitary.
5) Why does it matter if I am Primary or Secondary?
These concepts are important to understand, because you may be seeing a well meaning holistic practitioner who is selling you bags full of supplements to “heal” your adrenals – rather than doing a lab test to determine if there is a problem, and why. Some practitioners are vitamin experts – but unable to write the prescription you need, or order medical tests. There is no “cure” for secondary adrenal insufficiency, the replacement hormones need to be taken for life. Over-the-counter supplements will not provide the missing hormones, and will not restore your adrenal function to normal if you have secondary adrenal insufficiency. One medical site says that secondary adrenal insufficiency “is much more common than primary adrenal insufficiency and can be traced to a lack of ACTH.” http://endocrine.niddk.nih.gov/pubs/addison/addison.htm Remember, saliva based lab tests are great for measuring cortisol levels at various points in the day, but will not tell you if the problem is with the adrenal glands (primary) or with the pituitary (secondary). None of these tests can be performed while you are taking HC, adrenal cortex, or adrenal glandulars, or licorice supplements – so consider getting all testing done before starting medication.