Most people think of high blood pressure as something that runs in the family or just comes with age. They start medication, make small lifestyle changes, and hope it stays under control.
But what if your blood pressure has a hidden cause, one that medication or healthy habits alone can’t fix? It could be making you feel unusually tired or unwell, even as your heart works harder behind the scenes.
Doctors are finding that for some people, the reason lies deeper in the hormones that regulate the body’s balance of salt and water. One of those hormones, called aldosterone, is a steroid hormone that keeps sodium and potassium in balance, helping to control blood pressure.
When the adrenal glands produce too much of it, a condition known as Primary Aldosteronism or PA, the body holds on to salt and water while losing potassium. This can lead to blood pressure that often stays high despite treatment.
Why more people should know about it
Recent studies estimate that Primary Aldosteronism accounts for about 5–10% of hypertension cases, and rates may be even higher among people whose blood pressure remains high despite taking several medications.
Yet across Asia and around the world, most people with PA remain undiagnosed. Many doctors don’t routinely test for it, and patients rarely ask because they have never heard of the condition. In most clinics, the assumption is that high blood pressure is caused by lifestyle or genetics, not hormones.
This gap in awareness means many people may be living with a form of hypertension that could be treated more effectively if recognised. To understand why PA often goes undiagnosed, it helps to look at what happens inside the body.
Primary aldosteronism (PA) is recognised as one of the most common causes of secondary hypertension, yet it continues to be overlooked in clinical practice. Dr Ng, endocrinologist, explains that this often happens because PA goes undetected, especially in younger patients or those with treatment-resistant hypertension.
“PA is more common than many people realise, but it is underdiagnosed unless doctors are actively looking for it. Generally, patients who present with high blood pressure are assumed to have essential hypertension, which is the most common form that accounts for the majority of cases. Because of this, most people don’t undergo additional investigations and are instead managed with medication or advised on lifestyle measures such as weight reduction or dietary changes,” he says.
Suspicion for PA becomes stronger when a patient develops hypertension before the age of 40, or when blood pressure remains uncontrolled despite multiple medications. Yet without routine screening, many of these cases are missed. In Asian populations, including Singapore, studies suggest that PA may affect at least 5% of adults with hypertension.
What exactly is Primary Aldosteronism?
The adrenal glands, small structures located on top of the kidneys, produce several hormones that regulate stress response, metabolism, and blood pressure. One of them, aldosterone, signals the kidneys to retain sodium and water while excreting potassium. When too much of it circulates, the body loses more potassium than it can replace. This imbalance can leave you feeling weak or drained, even before blood pressure starts to climb.
PA is sometimes referred to as Conn’s syndrome, named after Dr Jerome W. Conn, who first described it in 1955. Technically, Conn’s syndrome refers to cases caused by a benign growth (adenoma) in one adrenal gland, but the term Primary Aldosteronism is now used more broadly to include both one-sided and two-sided forms of the condition.
There are two main causes of PA:
- A benign growth (adenoma) in one adrenal gland that produces too much aldosterone
- Both glands being overactive without a visible tumour
In both situations, the result is the same: excessive aldosterone and sustained high blood pressure.
When blood pressure remains high despite treatment with three or more medications, primary aldosteronism (PA) becomes a strong possibility. Globally, around 5–10% of all people with hypertension may have PA, and in resistant cases the figure can rise to 20% or more.
Classic warning signs include low potassium levels, although fewer than half of patients with PA actually present with this feature. More often, the condition reveals itself through a combination of factors such as younger age, lack of response to multiple therapies, and persistently elevated blood pressure.
The challenge is that PA does not usually present in an obvious way. Most people with the condition are asymptomatic, which means it is frequently missed unless clinicians actively consider and test for it.
Common symptoms that often go unnoticed
The signs of PA are often mistaken for stress, age, or lifestyle factors. You might notice:
Headaches or dizziness that may accompany elevated blood pressure
Fatigue or muscle cramps that may worsen after physical activity
Frequent urination or thirst
Tingling, numbness, or weakness in your limbs
High blood pressure that stays high, even on multiple medications
If your doctor has ever mentioned low potassium levels, that may be an important clue.
What happens if it goes untreated
If left untreated, PA can gradually damage the heart, kidneys, and blood vessels. Research shows that people with PA have a higher risk of:
Heart disease and stroke
Kidney disease
Irregular heart rhythm (arrhythmias)
Cognitive decline linked to long-term vascular damage
Changes in metabolism that can affect blood sugar levels
PA can be treated successfully, and some forms can even be cured.
Treatment depends on which glands are affected. Surgery can correct a single overactive gland, while medication helps when both glands are producing too much aldosterone. Either approach can improve blood pressure control and protect long-term health.
We tend to assume that if blood pressure looks controlled on medication, the risk is managed. But in cases of primary aldosteronism (PA), that isn’t the full story,” says Dr Ng. “In PA, the hormone aldosterone itself damages the heart, blood vessels, and kidneys, even when blood pressure appears normal. This means that compared with people who have regular hypertension, PA patients face a significantly higher risk of heart attacks, strokes, and kidney disease, unless the underlying aldosterone excess is specifically treated.
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When to ask for testing
Ask your doctor about PA if you notice any of the following:
The first step is usually a blood test that measures aldosterone and renin. If the balance between these two hormones is abnormal, your doctor may arrange confirmatory tests to verify the diagnosis.
What questions can I ask my doctor?
If you suspect a hormonal cause, these questions can make your consultation more productive:
Some forms of PA may have a genetic component, so relatives with high blood pressure might benefit from screening too.
How to explain your symptoms to your doctor
Because PA symptoms can resemble many other conditions, describing them clearly helps your doctor see patterns that routine tests might miss. Be as specific as you can by noting when symptoms occur, what affects them, and what changes you notice.
Specific details often reveal patterns that routine tests might miss. The more precise your description, the easier it is for your doctor to investigate the right causes.
Pay attention to when your symptoms appear or change during the day.
Notice what tends to make your symptoms improve or worsen.
If you’re taking medication, note how your body responds throughout the day.
Include other changes you’ve noticed, even if they seem unrelated.
Lifestyle changes such as reducing salt or increasing potassium can help in the management of primary aldosteronism (PA), but they rarely solve the problem on their own. Lowering salt intake and eating more potassium-rich foods, such as fruits and vegetables, can lessen some of the harmful effects of aldosterone. However, these measures don’t address the underlying issue, which is the overproduction of aldosterone itself. Most patients still require medication or, in some cases, surgery to treat the condition effectively.
Why diagnosis sometimes take time
Even in advanced healthcare systems, PA may go undetected for years because:
- Its symptoms mimic those of common conditions such as fatigue or dehydration
- Routine blood pressure check-ups do not include hormone tests
- Awareness among both patients and healthcare providers remains limited
Unlike cholesterol or blood sugar, there’s no standard screening test for hormone-related hypertension. Unless your doctor suspects a specific cause, the hormonal connection might not be investigated.
Being proactive and discussing ongoing symptoms, medication responses, and potassium levels can help prompt earlier testing. The same pattern of underdiagnosis is still seen across Asia, where awareness is still growing.
Primary aldosteronism (PA) can sometimes be cured, though in other cases it’s managed long term. Dr Ng explains that if one adrenal gland is overactive, surgery to remove it can cure the condition. When both glands are overproducing aldosterone, patients usually need ongoing medication instead. In either case, once treatment is initiated, outcomes are generally very good, provided the condition is recognised and addressed early.
This issue is particularly important in Singapore, where hypertension has risen sharply, from 19.8% of adults a decade ago to 37% in 2021–2022. If even 5% of these patients have (PA, a substantial number could remain undiagnosed. Recognising PA earlier is therefore critical, as timely treatment can lower the risk of long-term complications such as heart disease, stroke and kidney damage.
After starting treatment for PA, whether through surgery or long-term medication, patients usually report noticeable improvements in their health and daily life. Blood pressure becomes easier to control, potassium levels return to normal, and many report feeling more energetic and less fatigued. Over time, effective treatment also reduces the risk of cardiovascular and kidney complications, including cardiac arrhythmias linked to excess aldosterone.
However, long-term follow-up remains important. Patients should continue regular consultations with their doctor and monitor their blood pressure at home. For those on medication, adherence and periodic blood tests are essential to ensure hormone levels remain balanced. Even after successful surgery, ongoing monitoring helps maintain stable blood pressure and ensures lasting heart protection.
Why awareness matters in Asia
Across Asia, hypertension rates are rising as diets and lifestyles evolve. In Singapore, for example, 37 percent of adults had high blood pressure in 2021–2022, nearly double the figure a decade earlier.
If even 5 percent of these individuals have PA, that represents tens of thousands of people who could benefit from targeted treatment but may not yet know it.
Cultural habits, such as viewing tiredness as a normal part of ageing or hesitating to question medical advice, can delay diagnosis. Greater awareness helps people seek appropriate tests sooner.
A new way to think about blood pressure
Primary Aldosteronism challenges the idea that all high blood pressure is the same. It shows that what looks like a routine condition may, in some cases, have a specific and treatable cause.
In an age where health tracking focuses on numbers, PA reminds us that understanding the underlying systems matters just as much. If your blood pressure remains high despite medication, or if you’ve been told your potassium is low, it may be time to ask your doctor a simple question: “Could my blood pressure be related to my hormones?”
Better health often begins by asking the right questions.
Dr Ben Ng
Senior Consultant, Endocrinologist
Arden Endocrinology Specialist Clinic, Singapore
Facebook: Arden Endocrinology Specialist Clinic
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References
- Funder JW, Carey RM, Mantero F, et al. The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment. Hypertension. 2016.
- Monticone S, Burrello J, Tizzani D, et al. Prevalence and Clinical Manifestations of Primary Aldosteronism Encountered in Primary Care Practice. J Am Coll Cardiol. 2017.
- Frontiers in Endocrinology. Primary Aldosteronism: Current Concepts and Future Perspectives. 2022. Singapore Medical Journal. A Comparative Analysis on the Latest International Hypertension Guidelines. 2025.