A Functional Medicine Approach to Pheochromocytoma

One rare but often overlooked cause of high blood pressure caused by another medical condition (secondary hypertension) is pheochromocytoma. A pheochromocytoma is a rare tumor of the adrenal gland.

These growths of the middle part of the adrenal gland can cause high blood pressure and headaches due to their production of catecholamines. Usually, these tumors are benign (non-cancerous) and treatable. Pheochromocytomas most commonly occur in people between 30 and 50 years of age, although they are also seen in children.

Functional medicine offers an approach that looks at different factors involved in an individual’s symptoms and experience of disease. This holistic approach uses a multimodal management plan that addresses the patient’s needs, unique background, and individualized health issues. In this way, functional medicine offers an effective and personalized way to manage complex conditions like pheochromocytoma.

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What is Pheochromocytoma?

Pheochromocytomas are tumors that arise from the chromaffin cells of the adrenal medulla. Your adrenal glands are small endocrine organs that sit on each kidney just below your ribcage. These glands are made up of an outer layer called the cortex and a smaller inner portion called the medulla. 

The medulla secretes the catecholamine hormones adrenaline and noradrenaline (also known as epinephrine and norepinephrine) that help your body respond to stress by facilitating the “fight or flight” response. When you experience a stressor like exercise or low blood sugar, the adrenal medulla secretes epinephrine/adrenaline to help widen small arteries, increase blood pressure and heart output, and deliver oxygen to your muscles. In addition, it releases norepinephrine/noradrenaline that raises blood sugar, narrows blood vessels, raises blood pressure, and increases awareness and attention. 

While most pheochromocytomas are benign (non-cancerous), 10-15% are malignant (cancerous) and any of these tumors can cause symptoms in some cases. These tumors can be hard to detect and diagnose since they often do not cause any noticeable symptoms or cause symptoms that can be attributed to other causes.  

Since pheochromocytomas are made of the adrenal chromaffin cells that secrete these stress hormones, they can cause high blood pressure, headaches, sweating, shakiness, and a pounding fast heartbeat. Although sometimes there are no noticeable symptoms of pheochromocytoma, these tumors can cause dangerous blood pressure spikes known as a hypertensive crisis. 

Less commonly, pheochromocytomas can cause pain in the chest and/or abdomen, paleness, nausea, diarrhea, constipation, unexplained weight loss, or an extreme drop in blood pressure when standing up (orthostatic hypotension). Symptoms of pheochromocytoma can be triggered or exacerbated by intense physical activity, childbirth, anesthesia, surgery, intense emotional stress, physical injury, medications like dopamine receptor agonists, non-selective beta-blockers, tricyclic antidepressants, corticosteroids, sympathomimetics, and neuromuscular agents, or eating foods high in tyramine like red wine, chocolate, and cheese.

Functional Medicine Perspective on Pheochromocytoma

Pheochromocytomas are rare and can often be hard to recognize and diagnose, but functional medicine offers a holistic approach that can help. Functional medicine takes a holistic view of the patient’s health and listens thoroughly to her history and current experience. This is important when uncovering underlying factors that are contributing to a person’s symptoms.

When evaluating a patient for a possible pheochromocytoma, it is important to take a complete detailed medical history. This should include the patient’s medical history along with a thorough family medical history.

Functional medicine also brings a deep understanding of the body’s physiology and the interconnectedness among body systems. This includes recognizing the many factors that can contribute to changes in blood pressure and other symptoms seen in pheochromocytoma and how the adrenal glands communicate with and are connected with other body systems.

A functional medicine approach to pheochromocytoma looks at genetic, lifestyle, nutrition, emotional, and other factors. In approximately 25-35% of people with pheochromocytoma, a genetic condition gives rise to the condition. At least ten different genes have been associated with the development of these tumors. Hereditary conditions that are associated with pheochromocytoma include multiple endocrine neoplasia 2 syndrome types A and B (MEN2A and MEN2B), Von Hippel-Lindau (VHL) disease, neurofibromatosis type 1 (NF1), hereditary paraganglioma syndrome, and Carney-Stratakis dyad.

Diagnostic Approaches in Functional Medicine

If pheochromocytoma is suspected after completing a complete detailed medical and family history and a thorough physical exam, several diagnostic tests may help to narrow in on the diagnosis. Comprehensive health assessments and functional medicine testing can help to identify pheochromocytoma and differentiate it from similar conditions.

A functional medicine approach listens closely to the patient and utilizes an integrated approach to evaluate the differential diagnosis of pheochromocytoma. This includes hyperthyroidism, anxiety disorder, panic attacks, renal artery stenosis, hyperaldosteronism, migraine, cardiomyopathy, postural tachycardia syndrome (POTS), medication-induced high blood pressure, Cushing syndrome, and carcinoid.

Laboratory testing such as 24-hour urine and blood testing for metabolites of catecholamines are often the beginning steps for evaluating a suspected pheochromocytoma and differentiating this type of tumor from other neuroendocrine or hormonal conditions. These tests measure plasma-fractionated metanephrines or urinary-fractionated metanephrines in the body. Elevated levels of certain catecholamines and their metabolites in your urine or blood can be a sign of pheochromocytoma. It is important that this testing be performed under specific conditions to ensure accuracy. For example, blood should be drawn while the patient is lying down for at least 30 minutes before sampling.

For example, the Comprehensive Neurotransmitter Profile-24 hour by Doctor’s Data uses a 24-hour urine collection to evaluate the body's ability to secrete and metabolize various neurotransmitters including measuring norepinephrine, normetanephrine, epinephrine, metanephrine, and related neurotransmitters.

Imaging such as a CT scan or MRI are often used to look at the adrenal glands and assess for the presence of a tumor. Scanning the abdomen and pelvis is used to look for tumors. 

If a pheochromocytoma is confirmed, genetic counseling can help to evaluate the risk of a related inherited syndrome. In those whose pheochromocytoma is diagnosed before the age of 40, who have more than one tumor and/or tumors on both adrenal glands, and/or who have a family history of endocrine tumors, genetic testing may be carried out.

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Integrating Conventional and Functional Medicine Treatments

The optimal treatment of pheochromocytoma depends on many factors and should be individualized to the patient. Treatment approaches are tailored to the individual based on the size of the tumor, symptoms, hormone levels if the tumor is benign or malignant with any metastasis or recurrence, and other personalized factors.

Since pheochromocytoma involves the release of hormones that travel throughout the body and impact multiple organ systems, this complex condition requires a multidisciplinary approach to care. Functional medicine providers can work in conjunction with endocrinologists, surgeons, oncologists, obstetricians, cardiologists, palliative care, and primary care physicians to support and guide patients through treatment and beyond.

Depending on these factors, conventional treatment may include surgery, radiation, ablation, embolization, and/or chemotherapy to remove or shrink the tumor. In around 90% of cases, pheochromocytomas can be successfully removed with surgery such as an adrenalectomy to remove one or both of your adrenal glands.

When excess catecholamines are causing symptoms, medications are sometimes used. These can include alpha-blockers to normalize blood pressure, and beta-blockers to reduce elevated heart rate. A carefully titrated medication plan is also usually used around and during surgery to remove a pheochromocytoma to avoid precipitating a hypertensive crisis.

Medications may also be used to normalize adrenal hormone levels. For example, hormone replacement therapy may be used if both adrenal glands are surgically removed. If pheochromocytoma is metastatic, targeted therapy with the tyrosine kinase inhibitor sunitinib may be used to help prevent tumors from growing.

Functional medicine integrates with conventional treatment options for pheochromocytoma, such as surgery, to provide comprehensive care and optimize outcomes. Comprehensive pre- and post-operative care using functional medicine can help prepare the body for surgery and support recovery. These lifestyle, nutrition, and complementary medicine approaches help to balance inflammation, reduce complications, and support healthy recovery.

Nutritional and Lifestyle Interventions

Certain dietary and lifestyle habits may worsen or trigger the symptoms of pheochromocytoma. Nutrition and lifestyle interventions can support overall health in patients with pheochromocytoma and help manage symptoms.

An anti-inflammatory diet that is rich in fresh fruits and vegetables and avoids overly processed foods, added sugars, and chemical additives can support hormonal balance, inflammation, and immune system function. Focusing on plenty of high-fiber, anti-inflammatory plant-based foods can help to keep blood sugar, inflammation, and blood pressure levels more balanced.

Tyramine is a monoamine that is naturally found in plants, foods, and animals. It indirectly stimulates the release of catecholamines and can therefore exacerbate or trigger symptoms of pheochromocytoma including increasing blood pressure. Tyramine is high in foods that are fermented, aged, pickled, cured, overripe or spoiled. Foods rich in tyramine like red wine, chocolate, dried or smoked meats, and some cheeses should be avoided in pheochromocytoma.

Other foods can increase catecholamines in the body, triggering and/or mimicking symptoms of pheochromocytoma. These include coffee, tea, bananas, chocolate, cocoa, citrus fruits, and juices like orange juice, and vanilla. These foods should be avoided for several days before testing of catecholamine levels and to limit further elevations of catecholamines.

Keeping sodium, potassium, and other minerals in balance can also support more balanced blood pressure. Potassium helps to blunt the effects of sodium on the kidneys and supports the relaxation of blood vessels to reduce blood pressure. Incorporating potassium-rich foods like whole fruits and vegetables such as squash, apricots, and greens and legumes and beans like lentils and kidney beans while limiting added sodium can support more balanced blood pressure.

Managing Symptoms and Improving Quality of Life

Symptom management in pheochromocytoma is important for addressing the whole person and improving quality of life. A patient-centered approach to pheochromocytoma takes a personalized look at factors that impact an individual’s mind, body, and spiritual health to optimize quality of life. Looking at the root causes of imbalances and offering holistic strategies for managing common symptoms can help to effectively address each person’s needs.

While each person’s treatment plan will depend on several personalized factors and complete resolution of pheochromocytoma symptoms usually requires intervention to shrink or remove the tumor, such as surgery, additional strategies may be helpful for managing common symptoms of pheochromocytoma, such as high blood pressure, headaches, and sweating.

For example, a functional medicine approach looks at a wide range of underlying factors that can contribute to high blood pressure. These include dietary factors, like too much-added sodium and too little potassium, exercise, sleep, and stress. Addressing these components can be helpful when creating a multi-faceted holistic treatment plan individualized for each patient.

Looking at nutrient imbalances and repleting any deficiencies can also be helpful. For example, vitamin D deficiency is associated with elevations in blood pressure and some headaches so supplementing with this nutrient may be helpful in some cases to manage symptoms and improve quality of life.

Monitoring and Long-Term Management

Long-term management of adrenal tumors is important since recurrence can occur years after the initial tumor. Regular monitoring and follow-up in managing pheochromocytoma are needed to detect potential recurrence or metastasis.

The most common method of monitoring for pheochromocytoma recurrence is repeated blood and urine testing for increased levels of catecholamine metabolites each year. In some cases, such as when hormones are not produced by the original tumor, imaging studies like computed tomography (CT) scan, magnetic resonance imaging (MRI), or metaiodobenzylguanidine (MIBG) scan are used annually for at least 10 years.

Genetic testing of the tumor can help classify the degree of risk and guide the frequency and type of follow-up that is most appropriate. People with hereditary syndromes causing their pheochromocytoma generally require ongoing blood and urine screening along with imaging scans for the rest of their life.

Functional medicine provides a holistic approach to health management post-treatment of pheochromocytoma to optimize quality of life and health in all areas. This involves listening to the patient’s ongoing concerns and experiences and tailoring a lifestyle, dietary, and integrative approach that meets their unique needs.

Exploring Complementary Therapies in Pheochromocytoma Care

Since pheochromocytoma impacts the whole patient and many aspects of her health, mind, and body, various complementary therapies can be integrated with standard pheochromocytoma care to offer greater symptom management and well-being. Complementary therapies such as acupuncture, herbal supplements, and mind-body practices may be helpful as part of a holistic approach to integrative care in adrenal tumor management.

Traditional Chinese Medicine (TCM) views pheochromocytoma as related to one of several patterns of imbalance or disharmony in the body. These diagnostic patterns include kidney yang deficiency, kidney yin deficiency, liver yang rising, liver yin deficiency, and/or phlegm stagnation. 

Acupuncture is one modality utilized in TCM to bring balance back to the body. In this healing modality, very fine needles are inserted at meridian points to stimulate specific areas on the body that rebalance these patterns of disharmony. Acupuncture is effective for lowering blood pressure alone or when combined with antihypertensive medications to reduce dosage and thus side effects. A randomized control trial showed that acupuncture reduced blood pressure by 6.4/3.7 mmHg after six weeks of treatment in patients with mild-to-moderate hypertension.

Supplements can also be helpful in balancing the body and addressing symptoms like headaches and high blood pressure. One such supplement is the naturally-occurring antioxidant CoQ10 which is an important nutrient for mitochondrial energy production. A meta-analysis of 12 clinical trials showed that CoQ10 supported blood pressure reduction of as much as 16.6/10.3 mmHg when taken in doses of 60-120 mg daily for 6-12 weeks. Magnesium is another nutrient that supports balanced blood pressure and can help reduce the frequency of migraines and other headaches. In addition to supplementation, you can increase the consumption of magnesium in your diet by consuming plenty of green leafy vegetables, nuts, and whole grains.

Addressing Psychological and Emotional Health

Living with pheochromocytoma can be difficult and produce much understandable anxiety and stress. Studies show that people with pheochromocytoma more frequently experience anxiety and depression so it is crucial to consider mental health in pheochromocytoma care. Strategies such as counseling, support groups, and stress reduction techniques should be integrated into a personalized care plan to support mental and emotional health.

High blood pressure, anxiety, headaches, and flushing are some of the most prominent symptoms of pheochromocytoma. These symptoms can be triggered by and exacerbated by your nervous system’s reaction to physical or emotional stress, compounding symptoms and distress.

Incorporating stress management practices like yoga, meditation, and breathwork can help calm the nervous system and activate your parasympathetic response to counter some of the anxiety and stress. Taking time throughout each day to stop and engage in slow, deep breathing helps to shift the body into a more parasympathetic nervous system state by activating the vagus nerve to help reduce blood pressure. Regularly practicing these mind-body modalities can help you deal with the stress of living with a chronic condition and the treatments that you may undergo.

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A Functional Medicine Approach to Pheochromocytoma: Final Thoughts

Although rare, pheochromocytoma can cause intense anxiety and impair quality of life. This tumor of the adrenal medulla can be difficult to recognize and diagnose so a multidisciplinary and integrative approach is needed.

Functional medicine offers a comprehensive, patient-centered approach to recognizing and treating pheochromocytoma. A multifaceted approach personalized to the individual patient combines conventional treatments with functional and complementary therapies for optimal outcomes. Supporting all aspects of a patient’s health and life, before, during, and after treatment for pheochromocytoma is essential to the success of care and improving patient experience and outcomes.