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Adrenal disorders, from incidentalomas and Cushing’s to Conn’s and Addison’s.

Two small glands, a wide range of problems. A hub guide to the hormone tests, imaging and surgical decisions used in modern UK endocrine care.

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A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Editorial team

    Written by our editorial team from the UK sources listed on each page.

  • 02

    Sourced from guidance

    Checked against Endocrine Society, ESE, NICE and peer-reviewed UK sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK endocrine practice including incidentaloma workup, ARR screening and MEN surveillance.

Key facts

Adrenal disorders at a glance.

A single family of glands, several distinct diseases. The essentials of incidentalomas, hormone excess and hormone failure, in plain English.

  • What the adrenals do

    Two small glands above the kidneys that make cortisol, aldosterone and adrenal androgens plus adrenaline and noradrenaline from the medulla.

  • Incidentalomas

    Adrenal masses found by chance on CT or MRI. Present in around 7 per cent of adults over 70. Most are benign and non-functional.

  • Cushing’s syndrome

    Chronic cortisol excess causing central weight gain, hypertension, diabetes, osteoporosis and mood change. Needs biochemical screening before imaging.

  • Primary hyperaldosteronism

    Conn’s syndrome. Aldosterone excess causing resistant hypertension, often with low potassium. Under-diagnosed and often curable.

  • Addison’s disease

    Primary adrenal failure with cortisol and aldosterone deficiency. Presents with fatigue, weight loss, pigmentation and salt craving. Lifelong replacement needed.

  • Familial syndromes

    MEN2A, MEN2B and von Hippel-Lindau raise the risk of phaeochromocytoma. Congenital adrenal hyperplasia is inherited and often diagnosed in infancy or adolescence.

Why this guide matters

Small glands, big consequences.

Adrenal disease is easy to miss and easy to over-investigate. Three principles shape everything that follows.

  • Screen with hormones, not just imaging

    Every adrenal mass and every suspicion of hormone excess starts with the right biochemical screen before repeat scans or surgery.

  • Common problems are often missed

    Primary aldosteronism explains up to 1 in 20 cases of hypertension and is frequently overlooked. Screening changes lives.

  • Adrenal insufficiency is life-threatening

    Missed or under-replaced insufficiency leads to adrenal crisis. Education, a steroid card and an emergency injection kit prevent deaths.

How the diagnosis is made

From first suspicion to a clear plan.

The steps a UK endocrinologist follows to characterise an adrenal mass or diagnose hormone excess or deficiency.

  1. 01

    Assessing

    History and examination

    Blood pressure, weight change, skin, muscle strength, menstrual and mood history. A careful history often steers the whole workup.

  2. 02

    Assessing

    First-line hormone screen

    Depending on the picture: overnight 1 mg dexamethasone suppression for cortisol, aldosterone-renin ratio for hypertension with low potassium, plasma metanephrines for suspected phaeochromocytoma.

  3. 03

    Assessing

    Adrenal CT or MRI

    Non-contrast CT with attenuation measurement is the workhorse. MRI with chemical shift helps when radiation matters or the CT is inconclusive.

  4. 04

    Confirming

    Confirmatory endocrine tests

    Late-night salivary cortisol, 24-hour urinary free cortisol, saline suppression for aldosterone, short synacthen test for insufficiency.

  5. 05

    Confirming

    Localisation studies

    Adrenal vein sampling for lateralising aldosterone excess. MIBG or dotatate PET for phaeochromocytoma and paraganglioma.

  6. 06

    Planning

    Genetic testing when indicated

    Phaeochromocytoma, bilateral adrenal disease, young age or family history triggers referral to clinical genetics for MEN2, VHL, SDHx and NF1 panels.

  7. 07

    Planning

    Multidisciplinary planning

    Endocrinologist, adrenal surgeon, radiologist and anaesthetist agree on medical preparation, surgical approach and post-operative replacement.

Typical timeline: first clinic to a settled plan in weeks, sometimes months for complex cases.

The main adrenal disorders

One family of glands, several distinct conditions.

A short tour of each disorder. Deeper guides for phaeochromocytoma, Cushing’s, Addison’s and adrenal cancer are linked at the end.

  • Adrenal incidentaloma

    A mass found by chance on CT or MRI, present in around 7 per cent of adults over 70. Workup asks two questions. Is it functional and could it be malignant. Non-functional lesions under 4 cm with benign imaging are usually observed. Lesions over 4 cm or with suspicious features are considered for adrenalectomy.

  • Cushing’s syndrome

    Chronic cortisol excess. Causes divide into ACTH-dependent (pituitary Cushing’s disease and ectopic ACTH from lung or thymic tumours) and ACTH-independent (adrenal adenoma, carcinoma, hyperplasia and exogenous steroid use). Features include moon face, buffalo hump, purple striae, proximal myopathy, hypertension, type 2 diabetes, osteoporosis, hirsutism and easy bruising. Screening uses the overnight 1 mg dexamethasone test, late-night salivary cortisol or 24-hour urinary free cortisol.

  • Primary hyperaldosteronism (Conn’s)

    Autonomous aldosterone production from a unilateral adenoma or bilateral adrenal hyperplasia. Causes resistant hypertension, hypokalaemia and metabolic alkalosis. Screening uses the aldosterone-renin ratio. Saline suppression confirms the diagnosis, and adrenal vein sampling shows whether one side is responsible before surgery.

  • Phaeochromocytoma

    A rare catecholamine-secreting tumour of the adrenal medulla with paroxysmal hypertension, headache, sweating and palpitations. See our dedicated page for diagnosis, alpha and beta blockade, and surgical planning.

  • Adrenal insufficiency (Addison’s)

    Primary insufficiency is usually autoimmune destruction of the cortex, requiring loss of around 90 per cent of the gland before symptoms appear. Other causes include tuberculosis and the autoimmune polyendocrine syndromes APS1 and APS2. Secondary insufficiency reflects pituitary disease or prolonged exogenous steroid suppression. The short synacthen test confirms the diagnosis. Management is lifelong hydrocortisone and, in primary disease, fludrocortisone, with an emergency injection kit for every patient.

  • Virilising adrenal tumours

    Rare androgen-secreting adenomas and carcinomas cause rapid hirsutism, voice change and menstrual disturbance. DHEAS and testosterone are markedly raised. Imaging and prompt surgical review are essential to rule out carcinoma.

  • Familial adrenal syndromes

    Multiple Endocrine Neoplasia type 2A (MEN2A) and 2B (MEN2B) are associated with medullary thyroid cancer and phaeochromocytoma. Von Hippel-Lindau (VHL) disease causes CNS haemangioblastomas, renal cell cancer and phaeochromocytoma. Neurofibromatosis type 1 and the SDHx paraganglioma syndromes are also recognised. Any young or bilateral phaeochromocytoma prompts genetic referral.

  • Congenital adrenal hyperplasia

    Most often 21-hydroxylase deficiency. The classic form presents in infancy with salt-wasting and ambiguous genitalia in girls. The non-classical form presents later with hirsutism, acne, irregular periods and fertility problems, often mistaken for polycystic ovary syndrome. Treatment is with tailored glucocorticoid replacement and specialist follow-up.

Symptoms

What adrenal disease actually looks like.

Symptoms depend on which hormone is out of balance. The patterns below help clinicians decide which screening test to reach for.

  • Central weight gain and moon face

    Classic Cushingoid changes with a rounded face, supraclavicular fat pads and a buffalo hump behind the neck.

  • Purple striae and easy bruising

    Wide purple stretch marks on the abdomen or thighs and thin skin that bruises with minor knocks point to cortisol excess.

  • Resistant hypertension

    Blood pressure that needs three or more drugs, especially with low potassium, should trigger an aldosterone-renin ratio.

  • Proximal muscle weakness

    Difficulty rising from a chair or climbing stairs is a specific clue to Cushing’s syndrome.

  • Skin pigmentation and salt craving

    Bronzing of palmar creases, gums and scars with a strong salt craving suggests primary adrenal insufficiency.

  • New hirsutism or virilisation

    Male-pattern hair, voice change or clitoromegaly can point to androgen-secreting adrenal tumours. Rapid onset is a red flag.

  • Episodic sweating, headache and palpitations

    The phaeochromocytoma triad. Paroxysmal blood pressure spikes with anxiety-like episodes deserve urgent workup.

  • Red flag — adrenal crisis

    Vomiting, shock, low sodium and high potassium in someone on steroids or with Addison’s. A medical emergency needing IV hydrocortisone.

Treatment

How adrenal disorders are treated in the UK.

Ranges from watchful waiting through targeted medical therapy to laparoscopic and open adrenalectomy. Every plan is individualised.

  • Observation for small incidentalomas

    Non-functional lesions under 4 cm with benign imaging often need only interval review rather than repeat scans.

  • Adrenalectomy

    Laparoscopic removal for functioning adenomas, suspected malignancy and masses over 4 cm. Open surgery for large or invasive tumours.

  • Alpha and beta blockade

    Phenoxybenzamine or doxazosin followed by beta blockade prepares the patient for phaeochromocytoma surgery and prevents crisis.

  • Mineralocorticoid receptor antagonist

    Spironolactone or eplerenone for primary hyperaldosteronism when surgery is not suitable or the disease is bilateral.

  • Cortisol replacement

    Hydrocortisone in divided doses, sometimes with modified-release preparations, mimics the diurnal cortisol rhythm in adrenal insufficiency.

  • Fludrocortisone

    Daily mineralocorticoid for primary adrenal insufficiency to replace aldosterone and keep sodium, potassium and blood pressure steady.

  • Steroid-lowering medical therapy

    Metyrapone, ketoconazole or osilodrostat control cortisol in Cushing’s syndrome before surgery or when surgery is not possible.

  • Emergency hydrocortisone kit

    An IM hydrocortisone injection, steroid card and written sick-day rules for every patient with adrenal insufficiency.

What this guide is based on

The sources behind every claim on this page.

UK and international endocrine society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP or endocrinologist knows your history and can tell you which parts apply to you. If in doubt, get seen.

  • Endocrine Society and European Society of Endocrinology. Clinical practice guidelines on adrenal incidentaloma, Cushing’s syndrome, primary aldosteronism, phaeochromocytoma and adrenal insufficiency.

  • NICE Clinical Knowledge Summaries. Adrenal insufficiency, Cushing’s syndrome and secondary hypertension.

  • Society for Endocrinology UK. Emergency management of adrenal crisis in adults.

  • British Association of Endocrine and Thyroid Surgeons. Standards for adrenal surgery.

Red flags

When adrenal disease needs urgent attention.

Most adrenal disease is investigated calmly in an outpatient clinic. These are the situations where it is not.

  • Adrenal crisis

    Vomiting, shock, drowsiness and electrolyte disturbance. Give 100 mg IM or IV hydrocortisone and call 999 without waiting for tests.

  • Suspected phaeochromocytoma spike

    Severe headache, palpitations and sweating with a hypertensive surge. Avoid unopposed beta blockade and refer urgently.

  • Rapid virilisation

    Deepening voice, hirsutism or clitoromegaly developing over months raises concern for an androgen-secreting adrenal carcinoma.

  • Rapidly growing adrenal mass

    A mass that grows on interval imaging, is over 4 cm or has suspicious features on CT needs urgent surgical review.

  • Severe hypokalaemia with hypertension

    Potassium under 3.0 mmol/L with high blood pressure suggests Conn’s syndrome and needs endocrine referral before starting spironolactone blindly.

  • Missed steroid doses in Addison’s

    Any vomiting, fever or major illness in a steroid-dependent patient needs early dose doubling and low threshold for injection.

  • Pituitary red flags

    Headache, visual field loss or hypopituitarism in ACTH-dependent Cushing’s needs pituitary imaging and neurosurgical opinion.

  • Family history of MEN or VHL

    A first-degree relative with medullary thyroid cancer, phaeochromocytoma or CNS haemangioblastoma should prompt genetic referral.

  • Neonatal salt-wasting crisis

    Poor feeding, vomiting and shock in a newborn with ambiguous genitalia is congenital adrenal hyperplasia until proven otherwise.

Living with it

Well managed, adrenal disease need not limit life.

The four things that matter most day to day, whether you are on lifelong steroid replacement or being watched after adrenalectomy.

A quiet reminder

Preparation prevents crises.

A steroid card, a well stocked injection kit and clear sick-day rules head off almost every adrenal emergency at home.

  1. 01 Steroid card

    Always carry it

    Anyone on long-term steroid replacement should carry a steroid emergency card and wear medical ID at all times.

  2. 02 Sick-day rules

    Double the dose when unwell

    For fever, vomiting or infection, double oral hydrocortisone. Move to injection if vomiting stops absorption.

  3. 03 Follow-up

    Regular endocrine review

    Annual review of replacement doses, blood pressure, bone health and cardiovascular risk keeps things stable.

  4. 04 Life planning

    Pregnancy, surgery and travel

    Speak to your endocrinologist early. Doses often change in pregnancy and always need boosting around surgery and long-haul travel.

Frequently asked

Everything we get asked about adrenal disorders.

Quick answers on incidentalomas, Cushing’s, Conn’s, Addison’s and inherited adrenal syndromes.

  • What is an adrenal incidentaloma?

    A mass on an adrenal gland found by chance on a scan done for another reason. Around 7 per cent of adults over 70 have one. The two questions are always the same. Is it hormonally active and could it be malignant. Non-functional lesions under 4 cm with reassuring imaging are usually watched. Larger or suspicious lesions are considered for surgery.

  • What are the symptoms of Cushing’s syndrome?

    Central weight gain, a rounded moon face, a buffalo hump, wide purple stretch marks, easy bruising, proximal muscle weakness, high blood pressure, type 2 diabetes, osteoporosis, mood change and, in women, hirsutism and irregular periods. Screening uses an overnight 1 mg dexamethasone suppression test, late-night salivary cortisol or 24-hour urinary free cortisol.

  • What is Conn’s syndrome?

    Primary hyperaldosteronism. Excess aldosterone from an adrenal adenoma or bilateral hyperplasia causes hypertension that is often resistant to medication, with low potassium and metabolic alkalosis in more severe cases. The first-line screen is the aldosterone-renin ratio. Saline suppression confirms the diagnosis and adrenal vein sampling shows whether one side is responsible.

  • How is Addison’s disease diagnosed and treated?

    Primary adrenal insufficiency is confirmed with a short synacthen test showing a poor cortisol response. Treatment is lifelong hydrocortisone in divided doses to mimic the daily cortisol rhythm, plus fludrocortisone to replace aldosterone. Every patient needs a steroid card, sick-day rules and an emergency hydrocortisone injection kit.

  • When should I worry about a family history?

    Phaeochromocytoma, medullary thyroid cancer, bilateral adrenal disease, young age at diagnosis or several affected relatives should prompt referral to clinical genetics. Panels look for MEN2A, MEN2B, von Hippel-Lindau, neurofibromatosis type 1 and the SDHx genes that drive familial paraganglioma.

  • What is congenital adrenal hyperplasia?

    An inherited enzyme deficiency, most often 21-hydroxylase deficiency, that impairs cortisol production and drives excess androgens. Classic forms present in infancy with salt-wasting or virilisation. Non-classical forms present later with hirsutism, irregular periods or fertility problems and can be mistaken for polycystic ovary syndrome. Treatment is with glucocorticoid replacement and specialist follow-up.

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