Primary Hyperaldosteronism

What is primary hyperaldosteronism?

Primary hyperaldosteronism, sometimes called Conn’s syndrome, is a hormonal condition in which the adrenal glands make too much of a hormone called aldosterone. The adrenal glands are two small, triangle-shaped glands that sit on top of the kidneys. Aldosterone helps the body control blood pressure by telling the kidneys to hold on to sodium (salt) and water and to get rid of potassium. When the body produces more aldosterone than it needs, it retains too much salt and water and loses too much potassium. Over time this raises blood pressure and can lower the level of potassium in the blood.

Understanding what is primary hyperaldosteronism starts with the word “primary.” It means the problem begins inside the adrenal glands themselves, rather than being a normal response to something else in the body. This is different from secondary hyperaldosteronism, where the adrenal glands make extra aldosterone because of another condition, such as narrowing of the arteries that supply the kidneys.

Primary hyperaldosteronism is one of the most common identifiable causes of high blood pressure. It is often found in adults between roughly 30 and 60 years of age, although it can occur at other ages. Doctors particularly look for it in people whose blood pressure is difficult to control with several medications, in people who develop high blood pressure at a young age, and in people who have both high blood pressure and low potassium. Many people live with the condition for years without knowing it, because it is often mistaken for ordinary high blood pressure. Care for this condition is typically coordinated by hormone specialists, such as those in an Endocrinology & Metabolism department, often working together with heart and kidney specialists.

Symptoms of primary hyperaldosteronism

Primary hyperaldosteronism symptoms are often subtle, and many people have no obvious symptoms at all. In a large number of cases, the only sign is high blood pressure that is discovered during a routine check or that does not respond well to standard treatment. When symptoms do occur, they are usually related either to high blood pressure or to low potassium in the blood (a condition doctors call hypokalemia).

Possible symptoms include:

• High blood pressure — often moderate to severe, and frequently resistant to two or more blood pressure medications.
• Headaches — commonly linked to elevated blood pressure.
• Muscle weakness or muscle cramps — usually caused by low potassium.
• Fatigue — feeling unusually tired without a clear reason.
• Tingling or numbness — sometimes felt in the hands, feet, or around the mouth when potassium is very low.
• Frequent urination and increased thirst — low potassium can affect the kidneys’ ability to concentrate urine.
• Palpitations — an awareness of the heartbeat or an irregular heartbeat, which can occur when potassium is low.

How symptoms appear can differ depending on the type and stage of the condition. People with a single aldosterone-producing adrenal tumor (an adenoma, which is a benign, non-cancerous growth) often have higher aldosterone levels and are more likely to have noticeably low potassium and its related symptoms. People whose condition is caused by overactivity of both adrenal glands (called bilateral adrenal hyperplasia, meaning both glands are enlarged and overworking) often have a milder picture, sometimes with normal potassium and high blood pressure as the only clue. In early or mild disease, blood pressure may be only slightly raised; in long-standing, untreated disease, the effects on the heart, kidneys, and blood vessels can become more pronounced even if the person still feels reasonably well.

Because symptoms are so often absent or vague, primary hyperaldosteronism is frequently detected through blood tests rather than through complaints the patient notices.

Causes and risk factors

Primary hyperaldosteronism causes fall into a few main categories, all of which involve the adrenal glands producing aldosterone independently of the body’s normal control signals.

• Aldosterone-producing adenoma: A benign tumor in one adrenal gland that makes aldosterone on its own. This is one of the two most common causes. These tumors are almost always non-cancerous, but they disrupt hormone balance.
• Bilateral adrenal hyperplasia: Both adrenal glands become mildly enlarged and overactive, producing too much aldosterone. This is the other most common cause and tends to produce a somewhat milder form of the condition.
• Unilateral adrenal hyperplasia: Less commonly, only one adrenal gland is enlarged and overactive.
• Familial hyperaldosteronism: Rare inherited forms of the condition run in some families and can cause high blood pressure at a young age.
• Adrenal carcinoma: Very rarely, a cancerous adrenal tumor produces aldosterone. This is uncommon, but it is one reason imaging and specialist evaluation are important.

In many cases, doctors cannot say exactly why an adenoma or hyperplasia develops in a particular person. Certain factors raise the likelihood that high blood pressure is due to primary hyperaldosteronism rather than ordinary (essential) hypertension. These include:

• High blood pressure that begins before about age 40.
• Blood pressure that stays high despite taking three or more blood pressure medications (often called resistant hypertension).
• Low potassium levels found on blood tests, whether spontaneous or triggered by diuretics (water pills).
• An adrenal growth found incidentally on a scan done for another reason.
• A family history of primary hyperaldosteronism or of strokes at a young age.
• High blood pressure together with sleep apnea, a condition in which breathing repeatedly stops during sleep.

It is worth stressing that primary hyperaldosteronism is not caused by eating too much salt, although a high-salt diet can make its effects on blood pressure worse.

Diagnosis

Primary hyperaldosteronism diagnosis usually proceeds in three steps: screening, confirmation, and locating the source of the excess hormone.

Screening blood tests

The first step is a blood test that measures two hormones: aldosterone and renin. Renin is a hormone made by the kidneys that normally signals the adrenal glands to produce aldosterone. In primary hyperaldosteronism, aldosterone is high while renin is suppressed (low), because the adrenal glands are working independently of the kidneys’ signals. Doctors often calculate the aldosterone-to-renin ratio; a high ratio suggests the condition may be present. Some blood pressure medications can interfere with these tests, so your doctor may adjust your medications before testing. Potassium levels are usually corrected first as well, because low potassium can affect the results.

Confirmatory testing

A positive screening test is usually followed by a confirmatory test to show that aldosterone production cannot be switched off normally. There are several accepted methods, and the choice depends on the patient and local practice. Common approaches include:

• Oral salt loading: The patient eats a high-salt diet for several days, after which aldosterone in the urine is measured. In healthy people, extra salt suppresses aldosterone; in primary hyperaldosteronism, it does not.
• Saline infusion test: Salt water is given through a vein over a few hours, and blood aldosterone is measured afterward. Failure of aldosterone to fall supports the diagnosis.
• Other suppression tests: In some centers, medication-based suppression tests are used instead.

In certain clear-cut situations — for example, spontaneous low potassium with very high aldosterone and undetectable renin — doctors may consider the diagnosis confirmed without additional suppression testing.

Finding the source

Once the diagnosis is confirmed, the next question is whether one adrenal gland or both are responsible, because this determines treatment.

• CT scan (computed tomography): A detailed X-ray scan of the abdomen is used to look at the adrenal glands for a tumor or enlargement. It also helps rule out the rare possibility of a large, suspicious mass.
• Adrenal vein sampling: This is a specialized procedure in which a thin tube (catheter) is passed through a vein into the small veins draining each adrenal gland, and blood is sampled from each side to measure hormone levels. It shows which gland — or whether both glands — is producing the excess aldosterone. Adrenal vein sampling is generally considered the most reliable way to distinguish one-sided from two-sided disease, especially before surgery is considered, because scans alone can be misleading: small tumors may not appear, and harmless nodules that do not produce hormones are common, particularly in older adults.

Genetic testing may be suggested in young patients or when the condition runs in the family.

Treatment options for primary hyperaldosteronism

Primary hyperaldosteronism treatment depends mainly on whether the excess aldosterone comes from one adrenal gland or from both. The goals of treatment are to normalize blood pressure and potassium, and to reduce the long-term effects of excess aldosterone on the heart, blood vessels, and kidneys. Treatment plans are usually developed by an endocrinologist — a doctor who specializes in hormone disorders — often in a dedicated unit such as the endocrinology and metabolism department at hospital groups including Acibadem, together with surgeons and radiologists when needed.

Surgery for one-sided disease

When the excess aldosterone clearly comes from a single adrenal gland — most often because of a benign adenoma — surgery to remove that gland is usually the preferred treatment. The operation is called an adrenalectomy and is most often performed laparoscopically, meaning through several small incisions using a camera, which generally allows a shorter recovery than open surgery. The remaining adrenal gland typically takes over normal hormone production.

After successful surgery, low potassium usually resolves, and blood pressure improves in many patients. Some people are able to stop blood pressure medications entirely, while others still need medication but often at lower doses. The likelihood of blood pressure returning fully to normal depends on factors such as how long the person has had hypertension, their age, and whether there is other underlying blood pressure disease. Your medical team can discuss what a realistic outcome may look like in your individual case.

Medication for two-sided disease or when surgery is not suitable

When both adrenal glands are overactive (bilateral hyperplasia), or when a patient cannot or prefers not to have surgery, treatment is with medication. The main drugs used are mineralocorticoid receptor antagonists — medicines that block the effect of aldosterone on the body. These include:

• Spironolactone: A well-established aldosterone-blocking medicine. It is often effective at controlling blood pressure and correcting potassium, but at higher doses it can cause side effects such as breast tenderness or enlargement in men and menstrual irregularities in women, because it also affects other hormone receptors.
• Eplerenone: A more selective aldosterone blocker that causes fewer hormone-related side effects, though it may need to be taken more often and can be less potent dose for dose.

Additional blood pressure medications are sometimes needed alongside these drugs. Potassium supplements are occasionally used, although aldosterone blockers usually correct potassium on their own, and potassium levels need monitoring to avoid going too high once treatment starts.

Lifestyle measures and monitoring

Lifestyle changes support all forms of treatment but do not replace them. These typically include reducing dietary salt, maintaining a healthy weight, limiting alcohol, staying physically active, and not smoking. A truly “watch and wait” approach without any treatment is generally not recommended once the diagnosis is confirmed, because untreated aldosterone excess can damage the heart and kidneys over time even when symptoms are mild. However, ongoing monitoring — with regular blood pressure checks and periodic blood tests for potassium and kidney function — is an important part of care whether a person is treated with surgery or medication.

Living with primary hyperaldosteronism and outlook

For most people, the outlook with appropriate treatment is good. Once aldosterone excess is controlled — either by removing an overactive gland or by blocking the hormone with medication — potassium levels usually normalize and blood pressure typically becomes easier to manage. Treating the condition also appears to reduce the extra strain that excess aldosterone places on the heart, blood vessels, and kidneys compared with leaving it untreated.

That said, honest expectations matter. High blood pressure does not always disappear completely, especially in people who have had hypertension for many years or who have other contributing factors. Many patients continue to take at least some blood pressure medication after treatment. People managed with lifelong medication rather than surgery need ongoing follow-up to check blood pressure, potassium, and kidney function, and doses may need adjustment over time.

Day-to-day life with the condition is usually close to normal. Practical points that many patients find helpful include:

• Taking medications consistently and attending scheduled follow-up appointments and blood tests.
• Following a lower-salt diet, as advised by your care team, since salt intake directly influences how much the excess aldosterone raises blood pressure.
• Monitoring blood pressure at home if your doctor recommends it, and keeping a record to share at visits.
• Telling any new doctor or pharmacist about your diagnosis and medications, because some drugs can interact with aldosterone blockers or affect potassium.
• Discussing family screening with your doctor if the condition was diagnosed at a young age or runs in your family.

Untreated, long-standing primary hyperaldosteronism can contribute to complications of high blood pressure, including heart disease, stroke, atrial fibrillation (an irregular heart rhythm), and kidney damage. This is why identifying and treating the condition — rather than simply adding more blood pressure pills — is considered important.

Frequently asked questions

What is primary hyperaldosteronism in simple terms?

It is a condition in which the adrenal glands, small glands above the kidneys, make too much of the hormone aldosterone. This makes the body hold on to salt and water and lose potassium, which raises blood pressure and can cause low potassium in the blood. “Primary” means the problem starts in the adrenal glands themselves rather than being caused by another illness.

Can primary hyperaldosteronism be cured?

In many cases where a single adrenal gland is responsible, surgically removing that gland corrects the hormone excess, and some patients see their blood pressure return to normal or become much easier to control. When both glands are involved, the condition is usually managed long term with medication rather than cured, but it can typically be controlled effectively. No outcome can be guaranteed, and results vary from person to person.

How serious is primary hyperaldosteronism?

It is a treatable condition, but it should not be ignored. Excess aldosterone raises blood pressure and, over years, can strain the heart, blood vessels, and kidneys more than ordinary high blood pressure of the same level. With proper diagnosis and treatment, most people do well; the main risks come from the condition remaining undetected and untreated for a long time.

What are the most common primary hyperaldosteronism symptoms?

The most common finding is high blood pressure, often hard to control with medications. When symptoms occur, they may include headaches, muscle weakness or cramps, tiredness, tingling, increased thirst and urination, or palpitations, usually related to low potassium. Many people have no noticeable symptoms at all, which is why blood tests are so important for detection.

How do doctors confirm the diagnosis?

Diagnosis usually starts with a blood test measuring aldosterone and renin; a high aldosterone level with low renin suggests the condition. A confirmatory test — often involving salt given by mouth or through a vein to see whether aldosterone suppresses normally — usually follows. Finally, a CT scan and, in many cases, adrenal vein sampling are used to determine whether one gland or both are responsible, which guides treatment.

What is recovery like after adrenal surgery?

Adrenalectomy is most often done laparoscopically, through small incisions, and many patients leave the hospital within a few days and return to normal activities over a few weeks, although recovery times vary. Potassium levels often normalize quickly, while blood pressure may take weeks to months to reach its final level. Your care team will monitor your hormones, potassium, and blood pressure after surgery and adjust medications as needed.

Do I have to take medication for life?

It depends on the cause. If both adrenal glands are overactive, lifelong aldosterone-blocking medication such as spironolactone or eplerenone is usually needed, along with regular monitoring. If one gland is removed surgically, some patients can reduce or stop blood pressure medications afterward, while others still need some treatment. Never stop or change medications without discussing it with your doctor.

When to see a doctor

Talk to a doctor if you have high blood pressure that is hard to control despite taking several medications, if you developed high blood pressure before about age 40, if blood tests have shown low potassium, or if an adrenal growth was found on a scan done for another reason. A family history of primary hyperaldosteronism or of strokes at a young age is another reason to raise the question with your physician.

Seek urgent medical attention if you experience any of the following red-flag warning signs, which may indicate dangerously high blood pressure or severely low potassium:

• Severe muscle weakness or paralysis, especially if it comes on suddenly.
• Palpitations, a racing heartbeat, or an irregular heartbeat that does not settle.
• Chest pain or pressure, or severe shortness of breath.
• Sudden severe headache, confusion, vision changes, difficulty speaking, or weakness on one side of the body — possible signs of a stroke or a hypertensive emergency.
• Fainting or near-fainting episodes.
• Very high home blood pressure readings accompanied by any of the symptoms above.

Even without emergency symptoms, do not dismiss persistent high blood pressure or unexplained low potassium. Early evaluation by a doctor — and, where appropriate, referral to an endocrinology specialist — makes it more likely that primary hyperaldosteronism will be identified and treated before it causes lasting harm.