What are the adrenal glands?

The adrenal glands are glands located above the kidneys. They secrete hormones that are involved in various aspects of metabolism, including blood pressure, energy expenditure, sugar levels, salt levels, and immune response. Each adrenal gland is made up of two main parts, which produce different hormones. These are the adrenal cortex and the adrenal medulla.

What hormones are produced by the adrenal glands?

• Cortisol: This is a steroid hormone produced by the adrenal cortex. It is involved in maintaining blood pressure, regulating sugar and fat metabolism, and regulating energy expenditure.
• Aldosterone: This is a steroid hormone produced by the adrenal cortex. It is mostly involved in maintaining sodium and potassium levels by acting on the kidneys.
• Dehydroepiandrosterone: This is a steroid hormone produced by the adrenal cortex. It is a weak androgen and is a precursor hormone that is converted in the ovaries into oestrogen and in the testes into testosterone. However, oestrogen and testosterone are produced in much larger amounts by the ovaries and testes.
• Adrenaline: This is a hormone produced by the adrenal medulla. It increases energy expenditure, heart rate, and blood pressure in response to physically and psychologically stressful situations.
• Noradrenaline: This is a hormone produced by the adrenal medulla. It increases energy expenditure, heart rate, and blood pressure in response to physically and psychologically stressful situations.

What are adrenal disorders?

Common ways in which adrenal glands cause health problems are either by producing too little or by producing too much of certain hormones.

• Adrenal insufficiency: When the adrenal glands are underactive, they produce too little of certain hormones. This can be due to a disease of the adrenal glands themselves (Addison’s disease) or by a disease of the hypothalamus or pituitary gland (secondary adrenal insufficiency). Consequences include low sodium levels, high potassium levels, low blood sugar, low blood pressure, fatigue, weight loss, and nausea.
• Adrenal overactivity: When the adrenal glands are overactive, they produce too many of certain hormones. An excess of cortisol (Cushing’s syndrome) can result in high blood pressure, weight gain, diabetes, fatigue, muscle weakness, and easily bruised skin. An excess of aldosterone (Conn’s syndrome) can result in high blood pressure, high sodium levels, and low sodium levels.
• Phaeochromocytoma: This is a rare tumour of the adrenal medulla that results in increased production of adrenaline and noradrenaline. This results in high blood pressure, rapid heartbeat, tremors, sweating, and headaches.
• Congenital adrenal hyperplasia: This is a congenital condition where the adrenal glands produce an excess of androgens, which can result in ambiguous genitalia, masculinization in people born with ovaries, and precocious puberty in people born with testes.

Do adrenal disorders impact gender affirming hormone treatment?

Spironolactone is contraindicated as an antiandrogen in people who have adrenal disorders. This is because spironolactone influences the maintenance of blood pressure and the regulation of sodium and potassium levels, which are commonly affected in adrenal disorders. If you have an adrenal disorder and wish to commence feminising hormone treatment, an antiandrogen other than spironolactone is recommended.

Apart from spironolactone being contraindicated, having an adrenal disorder should not affect your gender affirming hormone treatment. Oestrogen and testosterone levels will be monitored as usual and your doses of oestrogen or testosterone can be adjusted accordingly.

Reference

• National Institute for Health and Care Excellence (2023). “Spironolactone: Cautions and Contraindications”. https://cks.nice.org.uk/topics/hypertension/prescribing-information/spironolactone/