Adrenal Hormones and InfertilityDr Asha S Vijay
The adrenal gland comprises two functional units; the medulla, which produces catecholamines, and the cortex, which makes mineralocorticoids (aldosterone and corticosterone), glucocorticoids (cortisol), and androgens.
For fertility, the cortex is the most important as it releases androgens. Androgens include DHEA (the precursor to estrogen), testosterone, androstenedione. Testosterone is the most recognized of all the androgens. Some of our progesterone is also produced by the adrenal glands as well. Following disorders related to the adrenal gland cause fertility issues:
1. Adrenal insufficiency
2. Adrenal fatigue or burnout
3. Classical congenital adrenal hyperplasia
4. Non classical congenital adrenal hyperplasia
Symptoms of Adrenal Hormonal Imbalances
• Low Libido
• Premature menopause, poor ovarian reserve
• Poor egg quality
• Sleep difficulty
• Anxiety or panic attacks
• Weight gain, cravings for carbs, salt, sugary foods
• Caffeine dependence
• Intolerance of cold
• Hair loss
• High blood pressure (associated with overly exerted adrenal function)
• Low blood pressure (associated with underactive adrenal function)
• Irritability, short temper
• Frequent illness, longer recovery time from illness or injury
Diagnosis of adrenal hormonal disorders is made by reviewing of patient’s symptoms and medical history, blood levels of cortisol, other adrenal hormones, sodium, potassium, and glucose to detect and help find the cause. They also look at the adrenal glands or the pituitary gland with imaging tests, such as x-rays, ultrasound, and CT or MRI scans.
Adrenal Insufficiency (Addison’s Disease):
Deficiency of adrenal hormones is caused by autoimmune factors, tuberculosis, various fungal and viral infections—impaired hypothalamic-pituitary corticotroph axis, drug-induced or surgical removal of adrenals.
The loss of adrenal androgens could influence fertility and increase spontaneous abortions. The leading cause of infertility is secondary ovarian insufficiency due to androgen deficiency, a substrate for ovarian hormone production. Concomitant diseases, such as autoimmune thyroid disease and premature cessation of ovarian function, are possible causes of reduced fertility in these patients. Fertility treatment includes supplementation of DHEA hormone, which reverses ovarian insufficiency secondary to androgen deficiency.
Adrenal Fatigue (Stress):
Excess stress raises cortisol levels and drops progesterone levels (both potential signs of infertility). The adrenals produce progesterone before converting it into cortisol. If the adrenals are exhausted, they will rob other progesterone sources. This impacts the reproductive cycle. Stress can cause anovulation and miscarriages. It also causes thyroid and prolactin hormone imbalances, contributing to infertility. Research tells us that stress boosts levels of stress hormones such as cortisol, which inhibits the body’s main sex hormones GnRH (gonadotropin-releasing hormone) and subsequently suppresses ovulation, sexual activity, and sperm count. Treatment mainly includes lifestyle modifications like yoga, regular exercise, a balanced nutritious diet, adequate rest, sleep, and mental peace.
Classical Congenital Hyperplasia
It is caused by a lack of enzymes in producing adrenal hormones. Presentation is at birth itself as it is congenital. The aetiology of infertility in patients with classic congenital adrenal hyperplasia stems from multiple factors, including virilization of the external genitalia, altered psychosocial development and impaired hypothalamic-pituitary-ovarian axis dynamics due to excess androgens, and hypersecretion of progesterone.
Nearly all patients with classic CAH require hormone treatment to ovulate. Regular glucocorticoids and mineralocorticoids are a part of the treatment to replace the deficient adrenal hormones. Although some patients will become ovulatory on their routine steroid maintenance therapy, others may require additional suppression of progesterone production.
Non-Classical Congenital Hyperplasia: NC-CAH
Patients with NC-CAH are usually asymptomatic at birth; it’s a sev0ere form of CAH. In adolescent and adult females, the symptoms of androgen excess include hirsutism, acne, menstrual irregularity, androgenic alopecia, and impaired fertility may be seen. Subfertility is relative in NC-CAH. Many females with NC-CAH conceive spontaneously, whereas others have ovulatory infertility but respond to glucocorticoid (GCC) or GCC plus clomiphene citrate treatment.
Adrenals also work closely with the ovaries to produce reproductive hormones. The balance is delicate. Hormonal disorders of adrenals are often missed or wrongly interpreted, resulting in unnecessary treatments, which are often unsuccessful. Adrenal workup should be done whenever necessary for correct diagnosis and successful treatment.