Tertiary adrenal insufficiency

What is tertiary adrenal insufficiency?

In the literature, an underactive adrenal cortex, which results from insufficient intake or incorrect dose reduction of cortisol, is often referred to as tertiary adrenal insufficiency.
In many diseases, especially inflammatory diseases, cortisol can improve symptoms. Sudden discontinuation of cortisol can lead to adrenal insufficiency due to the body's lack of self-production.

Causes of Tertiary Adrenal Insufficiency

In a variety of diseases, cortisol can relieve symptoms. Long-term cortisol therapy reduces the body's own production of the hormone.
The externally supplied cortisol particularly inhibits the release of ACTH, also known as adrenocorticotropic hormone. This is produced in the pituitary gland and naturally acts on the adrenal cortex or stimulates the production of the body's own cortisol as well as sex hormones or androgens.
Due to the suppressed cell function, tissue shrinkage in the ACTH-producing areas in the pituitary gland and in some cases also in the adrenal cortex occurs over time.
If the cortisol is then suddenly discontinued or the dose is reduced, the body cannot resume its function.
The result is a cortisol and androgen deficiency which, due to its development, is also referred to as tertiary adrenal insufficiency.

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Diagnosis

In order to diagnose adrenal insufficiency, in addition to a physical examination, the determination of special blood values ​​is necessary.
In particular, the cortisol concentration in the blood and the amount of ACTH are decisive parameters. In the case of tertiary adrenal insufficiency, the cortisol level is low, as is the ACTH.

Imaging methods such as ultrasound or computed tomography are also used. Above all, these serve to rule out other possible causes such as a tumorous disease.

In women, the androgen value (value of sex hormones) can also be determined; this is also reduced in the case of tertiary adrenal insufficiency.

Find out all about the topic here: ACTH

Symptoms of tertiary adrenal insufficiency

Typical symptoms of tertiary adrenal insufficiency are:

• low blood pressure
• Weight loss
• Powerlessness or exhaustion
• pale skin
• In women, a lack of androgen causes a decrease in the level of pleasure (loss of libido)

therapy

The treatment of the tertiary form of adrenal insufficiency is carried out as with the primary and secondary also, with the administration of cortisol. The amount of cortisol should also be adapted to the physical strain, i.e. the cortisol must be administered in higher doses in certain situations that put the body under stress.
These include, for example, feverish conditions, high physical demands due to sporting activity, trauma, severe stress, etc.

In addition, women may need to be given a steroid hormone. This is a substrate for the production of estrogen and testosterone and can be taken by affected women especially in the case of loss of sexual desire.

Prognosis of tertiary adrenal insufficiency

Tertiary adrenal insufficiency can generally be treated well. Renewed administration of cortisol compensates for the cortisol deficiency and the symptoms usually disappear quickly.
The tissue atrophy in the pituitary gland, which was previously caused by the long-term therapy with cortisol, remains. As with secondary adrenal insufficiency, the pituitary gland can no longer properly release ACTH and consequently no cortisol production takes place in the adrenal cortex.
Those affected are therefore still dependent on therapy with cortisol, as their own body can no longer properly perform its function.

Course of disease

The symptoms can be alleviated well through proper cortisol therapy. However, a cure for tertiary adrenal insufficiency is not possible.
The supply of cortisol or the amount may have to be adapted to certain situations by those affected. For example, if you have a cold with a fever, severe stress or intense physical activity. An increased intake in these life situations is particularly important in order to avoid complications, especially the Addison crisis. This can manifest itself in the context of adrenal insufficiency as a severe cortisol deficiency and requires immediate medical treatment.
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Difference from primary adrenal insufficiency

In primary adrenal insufficiency, an autocommunication reaction of the body is usually responsible for the loss of function. The body destroys the tissue of the adrenal cortex through misdirected processes. This is also known as autoimmune adrenalitis. The function of the adrenal cortex is disturbed and hormone production does not take place.
In addition to a cortisol and androgen deficiency, there is also no production of another hormone, the so-called aldosterone. This primarily affects the body's water and salt balance.
The symptoms of primary and tertiary hypofunction are very similar except for a few sub-items. In contrast to the tertiary form, a dark color of the skin is typical in primary insufficiency. Furthermore, the primary form can lead to a low sodium level and an increased potassium level in the blood due to the involved aldosterone deficiency.

Read our articles about this

• Addison's disease
• Symptoms of Addison's disease.

Difference to secondary adrenal insufficiency

In secondary adrenal insufficiency, there is an impairment of the function of the pituitary gland, also known as the adenohypophysis. Often it is a benign tumor that leads to such losses.
Without the action of the hormones produced by the pituitary gland, the adrenal cortex lacks the drive to produce cortisol and sex hormones (androgens).
Occasionally, tertiary adrenal insufficiency is also attributed to the secondary form, as both are associated with a loss of function of the pituitary gland, although different causes are responsible for the insufficiency. The symptoms of the two forms are basically no different.

Learn about the secondary adrenal insufficiency.