What are the most frequent questions we get at the Carling Adrenal Center?

• “Dr. Carling: I’m so worried I am going to have to take steroids after my adrenal surgery. Do I really need to take steroids (prednisone or hydrocortisone) after adrenal surgery? I am so concerned I am going to have adrenal insufficiency. I have read a lot about it online…I have googled adrenal insufficiency and Addison’s Disease a lot…”
  
  
• “Dr. Carling, can you please preserve my normal adrenal tissue, and just remove the tumor. Can you please perform a partial (adrenal-sparing) adrenalectomy?”

There exist a lot of myths, confusion, and erroneous information when it comes to steroid hormone replacement after adrenal surgery. Let’s address them here in this blog post.

Steroid replacement after adrenal surgery – 7 key facts and everything you need to know!

1) Dr. Carling and the Carling Adrenal Center will perform a cosyntropin stimulation test on 100% of patients at 4 am the morning after surgery. This assesses the normal function of cortisol production and the Hypothalamus-Pituitary-Adrenal (HPA) axis. No patient leaves the hospital without having their HPA axis and cortisol levels evaluated.

2) We all have 2 adrenal glands. It is enough to have about 30% of one adrenal gland to have normal adrenal gland function and hormone production. That is correct! You need only about 30% of one adrenal gland, or about 15% of each, to not require lifelong steroid replacement after adrenal surgery.

3) Dr. Carling is one of the world’s most experienced surgeons in partial (adrenal-sparing) adrenalectomy. Whenever possible, he preserves enough adrenal tissue so that you will not need lifelong steroid hormone replacement after surgery. This approach minimizes the risk of needing steroid replacement after adrenal surgery, and steroids are only prescribed if necessary.

Read more about partial adrenalectomy here:

https://www.adrenal.com/blog/when-is-partial-adrenal-surgery-the-best

Partial (adrenal-sparing) adrenalectomy

Figure 1. Dr. Carling and the team focus during the operation to ensure the best possible outcome during adrenal surgery.

4) Patients who have non-functioning adrenal tumors, pheochromocytomas (adrenaline type hormone-producing tumors), and primary aldosteronism or Conn’s syndrome (aldosterone-producing tumors) and have surgery on only one gland (assuming a normal contralateral gland) rarely need hormone supplementation after surgery. In most patients, the other contralateral adrenal gland simply will produce the appropriate amount of adrenal hormones needed to live a completely normal life. Because there are exceptions, every patient is tested the morning after surgery.

5) For patients requiring surgery for cortisol-producing adrenal tumors (adrenal hypercortisolism (AHC), formerly called MACS or subclinical Cushing syndrome), the need for steroid hormone replacement after surgery rises with the severity of the disease: roughly 30–50% of patients with mild AHC, 50–100% with moderate AHC and nearly all with severe AHC. Cortisol is tested the morning after surgery and steroid replacement is given only if needed. Recovery of the other contralateral adrenal gland takes months, and glucocorticoid withdrawal symptoms (fatigue, aches, low mood) are common and temporary.

6) For patients who have severe adrenal Cushing’s syndrome (the preoperative cortisol levels are super high, and the patient has suffered from the disease for years and decades), the other adrenal gland is suppressed. This means that the normal adrenal cells have been programmed to shut off cortisol production. Once Dr. Carling removes the tumor, the cortisol levels will drop. This is great news. The patient is cured of the high toxic cortisol levels. However, these patients will have a period of time of adrenal insufficiency because the normal adrenal cells are suppressed. The normal adrenal cells need to “wake up”. They have been put to sleep by the low ACTH levels. These are the patients that need steroid replacement after adrenal surgery. These patients may need to be on a low physiological dose of steroids (usually hydrocortisone, for several months and sometimes longer) while the adrenal gland wakes up. Dr. Carling’s nurse practitioner Meredith has extensive experience managing these patients. She will work with you before and after discharge from the hospital as well as all of your doctors during this period of time.

7) Dr. Carling and the Carling Adrenal Center regularly perform bilateral total adrenal operations (BLA) for “failed” Cushing’s Disease. This is in patients who have failed their treatment of a pituitary tumor, and then the necessary treatment is to remove all adrenal cells. This treatment essentially trades one really bad disease (Cushing’s Disease) for a more manageable disease (permanent adrenal insufficiency). These patients need to stay on steroid replacement after adrenal surgery for the rest of their lives. We will work with your doctors to manage this in the postoperative period to ensure that you have adequate adrenal hormone supplementation.

Read more here: https://www.adrenal.com/blog/the-best-cushing-s-disease-surgery-and-treatment

Background:

The adrenal glands play a pivotal role in the endocrine system, secreting essential steroid hormones such as cortisol, aldosterone, and dehydroepiandrosterone (DHEA). Adrenalectomy is performed for various medical conditions, including adrenal tumors and nodular adrenal disease. However, the removal of adrenal tissue may lead to a reduction or complete loss of steroid hormone production, resulting in adrenal insufficiency. Steroid hormone replacement therapy becomes imperative to mitigate the adverse effects of hormonal deficiency and maintain homeostasis.

Physiology of Adrenal Hormones:

Before delving into the intricacies of steroid replacement after adrenal surgery, it is crucial to understand the physiological roles of adrenal hormones. Cortisol, often referred to as the "stress hormone," regulates metabolism, immune response, and maintains blood pressure. Aldosterone is essential for electrolyte balance and blood pressure regulation, primarily by modulating sodium and potassium levels. DHEA, a precursor to sex hormones, contributes to various physiological processes, including the development of secondary sexual characteristics.

Adrenalectomy and Adrenal Insufficiency:

Adrenalectomy is a surgical procedure that may involve the removal of one (unilateral) or both (bilateral) adrenal glands. Common indications for adrenalectomy include adrenal tumors, adrenal hyperplasia, and certain cases of adrenal carcinoma. While the surgery may be lifesaving, in some patients it results in a temporary loss of adrenal hormone function (or a permanent loss when both glands are removed completely), leading to adrenal insufficiency. Adrenal insufficiency is characterized by symptoms such as fatigue, weight loss, hypotension, and electrolyte imbalances.

Go here to read up why we consider the Mini Back Scope Adrenalectomy (MBSA) the best operation for most adrenal tumors, and about Dr. Carling, one of the world’s most experienced adrenal surgeons:

https://www.adrenal.com/adrenal-surgery/mini-scope-surgery-best

https://www.adrenal.com/tobias-carling

Figure 2 shows aldosterone-producing tumors of the right and left adrenal glands, after partial right and left adrenalectomy. Dr. Carling preserved enough adrenal tissue, and the patient did not need steroid hormone replacement.

Importance of Steroid Hormone Replacement Therapy:

Steroid hormone replacement therapy serves as a cornerstone in managing adrenal insufficiency after adrenalectomy. The primary goal is to restore hormonal balance and ensure the proper functioning of essential physiological processes. Cortisol replacement, in particular, is critical for maintaining glucose homeostasis, regulating the immune system, and preventing adrenal crisis, a life-threatening condition characterized by severe cortisol deficiency.

Types of Steroid Hormone Replacement:

• Glucocorticoid Replacement: The most critical component of steroid hormone replacement post-adrenalectomy is glucocorticoid replacement, primarily aimed at replacing cortisol. Commonly prescribed glucocorticoids include hydrocortisone, prednisone, and dexamethasone. Hydrocortisone, with its shorter half-life, closely mimics the natural circadian rhythm of cortisol secretion, making it the preferred choice in many cases. The dosage is often divided into two or three daily administrations to replicate the diurnal cortisol variation.
  
  
• Mineralocorticoid Replacement: In cases where aldosterone secretion is compromised, mineralocorticoid replacement is necessary to maintain electrolyte balance and blood pressure. Fludrocortisone, a synthetic mineralocorticoid, is commonly prescribed. Monitoring of blood pressure, serum electrolytes, and renin levels is essential to adjust the dosage and prevent complications such as hypotension and hyperkalemia.
  
  
• DHEA Replacement: Dehydroepiandrosterone (DHEA) replacement may be considered in certain cases, as it serves as a precursor to sex hormones. However, its routine use is still a subject of debate, and individualized assessment is necessary to determine its appropriateness.

Challenges and Considerations in Steroid Hormone Replacement:

• Individualized Treatment: Steroid hormone replacement after adrenalectomy requires an individualized approach, taking into account the patient's age, gender, overall health, and the underlying reason for adrenalectomy. Dosage adjustments and medication selection may vary based on individual responses and the extent of adrenal tissue removal.
  
  
• Monitoring and Adjustments: Regular monitoring of cortisol levels, blood pressure, electrolytes, and other relevant parameters is crucial to assess the effectiveness of hormone replacement and make necessary adjustments. Close collaboration between the patient and the healthcare provider is essential to tailor the treatment plan according to the patient's evolving needs.
  
  
• Adrenal Crisis Prevention: Adrenal crisis, characterized by severe cortisol deficiency, is a medical emergency that can be life-threatening. Patient education on recognizing and managing adrenal crisis is paramount. The provision of an emergency injection kit containing parenteral hydrocortisone is often recommended, especially for patients at risk. APRN Meredith of the Carling Adrenal Center has extensive experience educating patients. Meredith will sit down with you, explain everything you need to know, and is always available to answer any questions you may have after discharge.

Conclusion:

Steroid hormone replacement therapy after adrenalectomy is a critical aspect of post-surgical care, aiming to restore hormonal balance and prevent complications associated with adrenal insufficiency. An individualized approach, regular monitoring, and patient education are key components in ensuring the effectiveness and safety of steroid hormone replacement. Ongoing research and advancements in the field hold promise for further optimizing treatment strategies and improving the long-term outcomes for individuals undergoing adrenalectomy. Comprehensive care, encompassing medical, psychosocial, and research aspects, is essential for addressing the multifaceted challenges posed by adrenal insufficiency post-surgery.

Dr. Tobias Carling, of the Carling Adrenal Center, is one of the world's leading experts in adrenal gland surgery. Dr. Carling has performed thousands of adrenal operations over his career, including more than 2,400 since January 2022 alone. Dr. Carling left Yale University in 2020 to open the Carling Adrenal Center in Tampa, Florida.

To discuss the details of your case with Dr. Carling and become his patient, fill out the new patient form and he will be in touch with you shortly.

Additional Resources: 

• Learn more about the Carling Adrenal Center
• Learn more about Dr. Tobias Carling
• Learn more about our sister surgeons at the Norman Parathyroid Center, Clayman Thyroid Center and Scarless Thyroid Surgery Center
• Learn more about the Hospital for Endocrine Surgery