Endocrine Abstracts

Background: Adrenal vein sampling (AVS) is well established for lateralising aldosterone excess in primary aldosteronism (PA) but its role in other steroid excess states such as hypercortisolaemia and hyperandrogenaemia remains less well defined. Diagnostic inconsistency arises from variation in stimulation protocols, reference hormone selection, and interpretative cut-offs across centres. In non-PA contexts, AVS is typically considered when imaging is inconclusive or when radiological findings, such as bilateral or unilateral adrenal abnormalities, raise uncertainty about the functional source.

Objective: To systematically review and assess application of use, consistency of AVS methodology and diagnostic cut-offs in the non-PA contexts of hypercortisolaemia and hyperandrogenaemia.

Methods: A systematic search of PubMed, Embase and Cochrane from 2015–2025 identified case reports, series, and cohort studies involving AVS in patients with hypercortisolaemia and hyperandrogenaemia. Data on stimulation/suppression protocols, reference hormones, selectivity index (SI), lateralisation index (LI), contralateral suppression, and clinical outcomes were captured.

Results: Forty-two studies were included, comprising variable protocols and thresholds. Cortisol was the most common reference hormone but proved unreliable in co-secreting states. Metadrenaline and adrenaline enabled a less confounded assessment of cannulation success, given their independence from cortisol production. SI thresholds ranged from 2.0–6.5 across both hypercortisolaemia and hyperandrogenaemia (reference hormone and stimulation protocol dependent). LI cut-offs for unilateral disease varied from ~ 2.0–4.0 in hypercortisolaemia and 2.0–2.3 in hyperandrogenaemia. Data on AVS in hyperandrogenaemia were limited and often lacked clear cut-offs. AVS has the potential to inform clinical management, for example decisions on adrenalectomy in bilateral disease.

Conclusion: AVS may have a meaningful role beyond PA, but methodological variation hinders reproducibility and clinical utility. These data highlight that further work on disease specific reference hormone selection, protocol adapted SI and LI thresholds, and a standardised reporting structure is required along with multicentre validation to improve clinical utility/outcomes.