Some people with high blood pressure that does not respond to typical treatment actually have the condition hyperaldosteronism. Hyperaldosteronism occurs when the adrenal gland releases too much of the hormone aldosterone into the blood. This is the most common hormonal or endocrine cause of hypertension or high blood pressure.
Primary hyperaldosteronism may be asymptomatic, especially early on. When symptoms are present, they may be related to hypertension (if severe), like headaches, flushing, and dizziness, and/or due to low potassium (hypokalemia), such as weakness, muscle cramping, and increased thirst and urination.
Since patients with primary aldosteronism have higher risks of cardiovascular complications, figuring out the root cause of high blood pressure and initiating proper treatment is crucial. A functional medicine approach to hyperaldosteronism looks at underlying factors and manages complications, cardiovascular risk factors, and additional underlying contributors to high blood pressure, including diet, exercise, sleep, and stress, to create a multi-faceted management plan.
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What is Hyperaldosteronism?
The adrenal glands are endocrine glands that sit on top of each kidney in the back of the body. They produce many important hormones, including aldosterone, cortisol, and adrenaline, to help regulate bodily functions, including blood pressure, electrolytes, metabolism, and your body's response to stress.
One of the functions of your adrenal glands is to produce the mineralocorticoid hormone aldosterone, which is released from the zona glomerulosa of the adrenal cortex. Aldosterone plays an important role in regulating blood pressure by regulating the balance of electrolytes like sodium and potassium, as well as water in your blood. This also impacts your blood pH or how acidic or basic it is. Aldosterone signals the kidneys to retain water and salt, increasing the amount of water in your body which increases your blood pressure.
The renin-angiotensin-aldosterone system normally serves to regulate blood pressure. Aldosterone works in conjunction with the hormone renin that is produced by the kidneys to regulate blood pressure and levels of sodium and potassium in your body.
When the adrenal glands produce too much aldosterone (hyperaldosteronism), your body loses too much potassium and retains too much sodium, which increases water retention, blood volume, and blood pressure.
Causes And Risk Factors for Hyperaldosteronism
Hyperaldosteronism can be either primary (autonomous) or secondary.
The primary type, also known as Conn's syndrome, is caused by a problem with one or both adrenal glands. In primary hyperaldosteronism, there is inappropriately elevated aldosterone production in the setting of low plasma renin. Aldosterone production continues from the adrenal glands independent of feedback about renin activity, potassium level, or volume status. This can happen due to being born with overactive adrenal glands, increased growth of the adrenal glands (hyperplasia), a benign tumor on one of the adrenal glands, or a rare aldosterone-producing cancerous tumor in the adrenal glands (adrenocortical carcinoma).
Secondary hyperaldosteronism occurs due to something outside the adrenal glands that triggers the increased production of aldosterone. It is most commonly due to reduced blood flow to the kidneys from issues like a blockage or narrowing of the renal artery, chronic liver disease, heart failure, or diuretic medications.
The excess aldosterone produced by any of the causes triggers the kidneys to increase the reabsorption of sodium and water and excrete more potassium. This causes your blood volume to increase, which puts more pressure on blood vessels, causing high blood pressure. Over time, this can cause chronic inflammation and heightened stress hormones (sympathetic drive) which can lead to the development of fibrosis in vital organs, such as the heart, kidneys, and blood vessels. As a result, chronic kidney disease, atrial fibrillation (a type of irregular heart rhythm), stroke, ischemic heart disease, and congestive heart failure can eventually develop.
Symptoms of Hyperaldosteronism
Primary and secondary hyperaldosteronism both present with common symptoms, including:
- high blood pressure (hypertension)
- low level of potassium in the blood
- feeling tired all the time
- headache
- muscle weakness
- numbness
Hyperaldosteronism is the most common cause of secondary hypertension or high blood pressure, which can range from moderate to severe. It is thought to be the cause of elevated blood pressure in around 20% of patients with hypertension that is resistant to topical treatment. Often the high blood pressure that occurs due to hyperaldosteronism does not respond to typical medication approaches. While high blood pressure commonly does not cause noticeable symptoms, it can result in headaches, dizziness, vision problems, chest pain, and shortness of breath.
Low potassium levels in the blood (hypokalemia) are also common with hyperaldosteronism and may cause fatigue, muscle cramping, increased thirst (polydipsia) and urination (polyuria), muscle weakness, and heart palpitations.
How is Hyperaldosteronism Diagnosed?
A thorough clinical history, family history, and physical exam measuring blood pressure can help raise the suspicion of hyperaldosteronism. Sustained high blood pressure above 150/100 mm Hg that is resistant to typical medications, low blood potassium, obstructive sleep apnea, a known adrenal mass, and/or a family history of hyperaldosteronism, other adrenal issues, or early-onset hypertension or stroke may prompt further screening.
When primary hyperaldosteronism is suspected, serum (or plasma) aldosterone and plasma renin can be measured with a blood draw for screening. A low renin (PRA <1 ng/mL/h) and elevated aldosterone level >10 ng/dL or a high aldosterone-renin ratio over 30 ng/dL per ng/mL/hour with a plasma aldosterone concentration of 15 ng/dL or higher suggest further testing is warranted.
Blood testing for potassium is also usually done. While studies suggest that only 9% to 37% of patients with primary aldosteronism have hypokalemia, classically, primary aldosteronism was suspected as the diagnosis in patients presenting with the triad of elevated blood pressure, low potassium in the blood, and an alkaline pH of the blood (metabolic alkalosis), which occurs when the condition is severe.
If the screening test is positive with a high aldosterone-renin ratio, confirmatory diagnostic testing is carried out to definitively confirm or exclude primary aldosteronism. This can be done with oral sodium suppression, saline infusion suppression, fludrocortisone suppression, and a captopril challenge test which are all interventions that should normally suppress aldosterone production. If persistent aldosterone production occurs, this indicates autonomous renin-independent production of aldosterone, which confirms a diagnosis of primary aldosteronism.
CT or MRI, imaging scans of the abdomen, can check for any tumors on or around the adrenal glands.
Another technique for detecting hyperaldosteronism and determining its cause is adrenal vein sampling. This minimally-invasive interventional radiology procedure involves taking a blood sample directly from the veins of each adrenal gland and testing the amount of aldosterone in it. If the blood from one gland has significantly higher aldosterone, there may be a tumor producing aldosterone there. If blood from both glands has similarly elevated levels of aldosterone, both glands are likely overactive and may be enlarged.
Functional Medicine Labs to Test That Can Help Individualize Treatment Options for Patients With Hyperaldosteronism
Functional medicine testing can help to measure the function of the adrenal glands and monitor the management of hyperaldosteronism and related complications.
Aldosterone
Aldosterone can be measured in blood or serum along with plasma renin activity (PRA) to assess the renin-angiotensin-aldosterone system that is involved in regulating blood pressure. People with hyperaldosteronism generally have high aldosterone levels and low renin levels.
Cardiovascular Evaluation
A cardiovascular evaluation is important to monitor the impacts of hyperaldosteronism and any cardiovascular complications. This should include a complete blood count (CBC), a complete metabolic profile (CMP) which can evaluate potassium and sodium levels as well as other electrolytes and kidney function, high-sensitivity CRP (hs-CRP), a lipid panel, and urinalysis. When evaluated together, these labs can screen for anemia, cholesterol issues, kidney disease, and cardiovascular inflammation. This information allows for the assessment of cardiovascular disease and risk as well as screening for end-organ damage due to high blood pressure.
Electrolyte Balance
In addition to a complete metabolic profile (CMP) that measures electrolytes like potassium and sodium in the blood, urine testing can also evaluate electrolyte balance. Urine collected from the time of going to bed until the first voiding the next morning can be examined for sodium and potassium levels to assess the success of the dietary approaches to limiting sodium. When following the DASH diet, a sodium/potassium ratio of < 1 indicates the DASH target has been reached. The lower the ratio, the lower the sodium level and the more potassium intake was the day before.
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Integrating Conventional and Integrative Approaches
Treating hyperaldosteronism requires reducing elevated aldosterone levels and/or blocking the effects of aldosterone to address the impacts of high blood pressure and low blood potassium. A conventional and functional medicine approach can work together to address the whole person with a personalized treatment plan. For example, natural compounds in food and nutraceutical supplements, vitamins, antioxidants, or minerals, can function in a similar fashion to certain antihypertensive medications and work synergistically with conventional approaches.
Collaboration between conventional practitioners like endocrinologists and surgeons and integrative medical practitioners offers patients a comprehensive approach to managing their health and well-being. Knowledge of nutrient status and functional medicine testing and strategies can complement the management of conventional medications. For example, checking and repleting possible nutrient deficiencies caused by blood pressure medications can help keep the body balanced.
This is the most effective way to manage hyperaldosteronism complications, cardiovascular risk factors, and additional underlying contributors to high blood pressure, including addressing diet, exercise, sleep, and stress, to create a multi-faceted management plan.
Conventional Treatment Options for Hyperaldosteronism
Treatment for hyperaldosteronism depends on the cause of elevated aldosterone but generally includes normalizing blood pressure, electrolytes, and aldosterone levels.
Treatment of hypertension is done by reducing aldosterone levels and/or blocking the effects of aldosterone. One conventional approach is the medication spironolactone which is a mineralocorticoid receptor antagonist or blocker. It blocks the effects of aldosterone on your body. Newer medications like eplerenone have even greater specificity for the mineralocorticoid receptor than spironolactone and can significantly reduce high blood pressure in patients with hyperaldosteronism. Long-term use of medicines that block the effects of aldosterone, such as spironolactone and eplerenone, can sometimes cause side effects, including erectile dysfunction and gynecomastia (enlarged male breast tissue) or spotting between menses and breast tenderness. These medications should also be used with contraception due to potential teratogenic effects on a male fetus.
If a tumor or overgrowth of the adrenal glands is causing too much aldosterone, surgery to remove the adrenal gland (adrenalectomy) may be used. A laparoscopic approach is generally preferred as it is associated with fewer complications and a shorter hospital stay.
Integrative Nutritional Interventions for Patients With Hyperaldosteronism
Research shows that a low-sodium, potassium-rich diet is effective in lowering blood pressure and raising serum potassium levels in people with idiopathic hyperaldosteronism. An anti-inflammatory diet focused on whole, unprocessed foods can help you maintain a healthy weight and blood pressure. Incorporating elements of the Dietary Approaches to Stop Hypertension (DASH) diet which limits added salt intake, can help manage blood pressure. This dietary approach focuses on fruits, vegetables, nuts, and lean meats that overall lead to increased calcium, potassium, magnesium, and protein intake while limiting sodium, sugar, and processed saturated fats.
High sodium intake can contribute to high blood pressure and further strain the kidneys. It is recommended to limit sodium intake to less than 2,300 mg or the amount of sodium in 1 teaspoon of table salt per day or a stricter version that restricts sodium to 1,500 mg a day, balanced with 4,700 mg of potassium per day. Potassium acts at a cellular level to blunt the effects of sodium and support the relaxation of blood vessels to help keep blood pressure balanced. Potassium-rich fruits and vegetables include apricots, lentils, squash, kidney beans, and spinach.
Supplements and Herbs for Patients With Hyperaldosteronism
Magnesium is required for muscle relaxation and energy metabolism, with supplementation of 500-1,000 mg daily supporting heart contractility and vasodilation, helping to reduce blood pressure up to 5.6/2.8 mmHg. Magnesium deficiency can be caused by a diet lacking green leafy vegetables, nuts, and whole grains, as well as chronically elevated stress.
Aged garlic extract stimulates nitric oxide production and activity while inhibiting angiotensin-II to help balance physiologic factors that increase blood pressure. Garlic preparations can help to lower blood pressure and balance serum cholesterol levels to improve cardiovascular health.
Vitamin D deficiency is associated with elevated blood pressure and cardiovascular risk. Studies show that supplementing vitamin D results in lowered blood pressure.
CoQ10 is an antioxidant that is required for mitochondrial energy production. A meta-analysis of 12 clinical trials concluded that CoQ10 helps to lower blood pressure by as much as 16.6/10.3 mmHg when given in doses of 60-120 mg daily for 6-12 weeks.
Mind-Body Techniques for Patients With Hyperaldosteronism
Practices like breath work, yoga, tai chi, qi gong, and relaxation exercises help balance blood pressure by shifting the body from a sympathetic state into a parasympathetic state, which allows for a more relaxed physiologic state.
For example, breathwork-like controlled nose-breathing practices provide cardiovascular and stress-relieving benefits. Slow, deep breathing and meditation increase parasympathetic nervous system activity by activating the vagus nerve to help reduce blood pressure.
Smoking is the single most modifiable risk factor for cardiovascular health, including high blood pressure, so stopping smoking is an important lifestyle step for managing hyperaldosteronism and its complications. Smoking contributes to oxidative damage and arterial stiffening, which can raise blood pressure.
Acupuncture And Traditional Chinese Medicine for Patients With Hyperaldosteronism
In Traditional Chinese Medicine, hyperaldosteronism is explained by one of four so-called "patterns of disharmony"-- Spleen or Kidney Yang Deficiency, Exterior Cold invading the Interior, Spleen Yang Deficiency, or Kidney Yang Deficiency depending on the specific symptom pattern.
Acupuncture is a modality utilized in TCM where very fine needles are used to stimulate specific points on the body to help balance these patterns of disharmony. Studies show that acupuncture is effective for reducing blood pressure as a stand-alone therapy or alongside antihypertensive medications. It can help reduce the need for higher medication doses and thus reduce side effects. A randomized control trial of patients with mild-to-moderate hypertension found that acupuncture led to an average reduction in blood pressure of 6.4/3.7 mmHg after six weeks of treatment.
Physical Activity And Exercise for Patients With Hyperaldosteronism
Exercise is a great way to keep the heart healthy and help to manage blood pressure and weight. Enjoying 30 minutes of moderate-intensity physical activity on most days of the week lowers blood pressure by 5-8 mmHg and reduces the risk of cardiovascular disease. Additionally, any needed weight loss associated with routine exercise can improve blood pressure readings by 1 mmHg for every 2.2 lbs lost. Regular exercise also helps mitigate muscle and bone damage caused by excess aldosterone.
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Summary
Hyperaldosteronism occurs when the adrenal glands release too much aldosterone, most commonly due to a noncancerous (benign) tumor of the adrenal gland. Since excess aldosterone triggers the kidneys to increase the reabsorption of sodium and water and excrete more potassium, your blood volume increases, which puts more pressure on blood vessels, causing high blood pressure. This high blood pressure and low levels of potassium in the blood, which occurs in hyperaldosteronism, can make you feel tired all the time, have headaches, and experience muscle weakness or numbness.
Primary hyperaldosteronism caused by an adrenal gland tumor or hyperplasia is often treated with surgery. Medications may also be used to block the impacts of aldosterone and lower blood pressure. Functional medicine testing can help to measure the function of the adrenal glands and monitor the management of hyperaldosteronism and related complications.
A low-sodium, high-potassium anti-inflammatory diet is effective in lowering blood pressure and raising serum potassium levels in people with hyperaldosteronism. Incorporating moderate-intensity physical activity on most days of the week lowers blood pressure and mitigates muscle and bone damage caused by excess aldosterone. Practices like breath work, yoga, tai chi, qi gong, and relaxation exercises help balance blood pressure by shifting the body from a sympathetic state into a parasympathetic state. Supplements like magnesium, garlic, vitamin D, and coQ10 may help lower blood pressure and prevent cardiovascular complications from developing.
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