2006 medical lecture - Addison's Disease Self Help Group

Sex and Addison’s: how adrenal insufficiency
affects men and women differently
ADSHG medical lecture 2006 Professor Wiebke Arlt
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Sex and Addison’s: how adrenal insufficiency
affects men and women differently
ADSHG medical lecture 2006
Professor Wiebke Arlt (continued)
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Sex and Addison’s: how adrenal insufficiency
affects men and women differently
ADSHG medical lecture 2006
Professor Wiebke Arlt (continued)
Despite pressing family commitments and a struggle with the
tube, I was determined to attend the medical lecture to see some
friendly faces and hear some juicy pointers on Addison’s and sex – I
had somehow ignored the subtitle in my excitement. Professor
Arlt opened her talk with the history of Dr Thomas Addison and
the discovery of Addison’s in the 1850s. She made the interesting
observation that four times more women than men develop
Addison’s disease, and that women are more likely to develop
a second endocrine condition, most often a thyroid condition
or ovarian failure. Asthma and psoriasis are high contenders for
accompanying (nonendocrine) autoimmune conditions, with asthma
more common in women and psoriasis in men.
Age also became a significant difference between the sexes, with
men most likely to be diagnosed with Addison’s disease between
20-29 and women between 30-50 years. Professor Arlt then
illustrated the problems with diagnosis by comparing two hospital
admissions. Typically, it is the tan that initially hinders diagnosis –
because patient looks so well – while its association with extreme
fatigue then achieves it.
Looking at replacement therapy, Professor Arlt ‘asked the audience’
and found the majority on hydrocortisone, with a few people
taking prednisolone or cortisone acetate. The question on many
lips was the usefulness of day curves. Professor Arlt explained that
day curves are useful to track how serum cortisol is used by the
body, but stressed they are only helpful if there is a record of the
time the replacement hydrocortisone is taken. She then explained
why mineralcorticoid replacement – the drug fludrocortisone - is
required. Quite simply put, it is a blood pressure assistant. If the
individual is on too little fludrocortisone, they will usually experience
dizziness when standing up, and muscle cramps are also common.
Hydrocortisone exerts a small amount of fludrocortisone activity in
the body, therefore if there is a change in the type of replacement
or the amount of hydrocortisone taken, it can affect fludrocortisone
levels. At last I understand why I get cramps in hospital when I get
put onto dexamethasone for emergency treatment!
This was further explored by looking at the extra hydrocortisone
requirements during surgery and in times of infection. When the
hydrocortisone is increased to more than 50mg for illness or surgery,
this has a fludrocortisone activity equivalent to 100mcg. So anyone
whose normal fludrocortisone dose is 100mcg can probably safely
stop taking it until they taper their hydrocortisone to less than
50mg.
Plasma renin is the most sensitive test of whether an individual is
getting enough fludrocortisone, but it is not always reliable. It is not
accurate during pregnancy, because of the additional pregnancy
hormones in circulation, and it is likely to give a misleadingly low
reading for anyone who also has diabetes or who is taking NSAIDs.
In these circumstances it is best to rely on the broader indicators:
blood pressure, sodium and potassium. Professor Arlt then
tackled the management of Addison’s during pregnancy, with the
observation that both fludrocortisone and hydrocortisone may need
to be increased as the pregnancy advances, while high doses of
intramuscular hydrocortisone are needed during delivery.
Professor Arlt closed her presentation with a look at DHEA. The
question of whether people with Addison’s need DHEA seems to
be answered with a resounding yes. Tests are continuing to study
whether immune function is improved on DHEA, and Professor
Arlt has some results in the pipeline here. Studies show that people
with Addison’s subjects report fatigue, dry skin and low libido as
significant problems while on standard steroid replacement therapy;
these symptoms are improved by DHEA. Women with Addison’s are
noticeably more affected by low libido than men and report more
improvement on DHEA replacement. In clinical trials conducted by
Professor Arlt, four months of DHEA replacement therapy restored
androgens to normal levels, which boosted sexuality. And this
improvement has been observed and reported by the spouses of
women taking part in clinical trials as well. Now that’s the juicy bit I
was waiting for!
Claire Allen
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