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hormone cortisol for a long time. The most common cause of Cushing' s syndrome, sometimes called hypercortisolism, is the use of oral corticosteroid medication. The condition can also occur when the body makes too much cortisol. Too much cortisol can produce some of the hallmark signs of Cushing's syndrome a fatty hump between the shoulders, a rounded face, and pink or purple stretch m arks on the skin. Cushing's syndrome can also result in high blood pressure, bon e loss and, on occasion, diabetes. Treatments for Cushing's syndrome can return the body's cortisol production to normal and noticeably improve the symptoms. Th e earlier treatment begins, the better the chances for recovery. Symptoms Cushing's syndrome Common Cushing's syndrome symptoms include: Weight gain, particularly around your midsection and upper back
Fatigue Muscle weakness Rounding of your face (moon face) Facial flushing Fatty pad or hump between your shoulders (buffalo hump) Pink or purple stretch marks ( striae) on the skin of your abdomen, thighs, breasts and arms Thin and fragile s kin that bruises easily Slow healing of cuts, insect bites and infections Depres sion, anxiety and irritability Loss of emotional control Thicker or more visible body and facial hair (hirsutism) Acne Irregular or absent menstrual periods in females Decreased libido Erectile dysfunction in males New or worsened high bloo d pressure Glucose intolerance that may lead to diabetes Headache Bone loss, lea ding to fractures over time When to see a doctor If you're taking corticosteroid medications to treat a cond ition, such as asthma, arthritis or inflammatory bowel disease, and experience s igns and symptoms that may indicate Cushing's syndrome, see your doctor for an e valuation. Even if you're not using these drugs and you have symptoms that sugge st the possible presence of Cushing's syndrome, contact your doctor. Causes Adrenal glands
Endocrine system Your endocrine system consists of glands that produce hormones, which regulate p rocesses throughout your body. These glands include the adrenal glands, pituitar y gland, thyroid gland, parathyroid glands, pancreas, ovaries (in females) and t esticles (in men). Your adrenal glands produce a number of hormones, including c ortisol. Cortisol plays a variety of roles in your body. For example, cortisol h elps regulate your blood pressure and keeps your cardiovascular system functioni ng normally. It also helps your body respond to stress and regulates the way you convert (metabolize) proteins, carbohydrates and fats in your diet into usable energy. However, when the level of cortisol is too high in your body, you may de velop Cushing's syndrome. The role of corticosteroids Cushing's syndrome can dev elop from a cause that originates outside of your body (exogenous Cushing's synd rome). Taking corticosteroid medications in high doses over an extended period o f time may result in Cushing's syndrome. These medications, such as prednisone, dexamethasone (Decadron) and methylprednisolone (Medrol), have the same effects as does the cortisol produced by your body. Your doctor may prescribe corticoste roids to treat inflammatory diseases, such as rheumatoid arthritis, lupus and as thma, or to prevent your body from rejecting a
transplanted organ. Because the doses required to treat these conditions are oft en higher than the amount of cortisol your body normally needs each day, the eff ects of excess cortisol can occur. People can also develop Cushing's from inject able corticosteroids for example, repeated injections for joint pain, bursitis a nd back pain. While certain inhaled steroid medicines (taken for asthma) and ste roid skin creams (for skin disorders such as eczema) are in the same general cat egory of drugs, they're generally not implicated in Cushing's syndrome unless ta ken in very high doses. Your body's own overproduction The condition may also be due to your body's own overproduction of cortisol (endogenous Cushing's syndrom e). This may occur from excess production by one or both adrenal glands, or over production of the adrenocorticotropic hormone (ACTH), which normally regulates c ortisol production. In these cases, Cushing's syndrome may be related to: A pituitary gland tumor. A noncancerous (benign) tumor of the pituitary gland, l ocated at the base of the brain, secretes an excess amount of ACTH, which in tur n stimulates the adrenal glands to make more cortisol. When this form of the syn drome develops, it's called Cushing's disease. It occurs much more often in wome n and is the most common form of endogenous Cushing's syndrome. An ectopic ACTHsecreting tumor. Rarely, when a tumor develops in an organ that normally does no t produce ACTH, the tumor will begin to secrete this hormone in excess, resultin g in Cushing's syndrome. These tumors, which can be noncancerous (benign) or can cerous (malignant), are usually found in the lung, pancreas, thyroid or thymus g land. A primary adrenal gland disease. In some people, the cause of Cushing's sy ndrome is excess cortisol secretion that doesn't depend on stimulation from ACTH and is associated with disorders of the adrenal glands. The most common of thes e disorders is a noncancerous tumor of the adrenal cortex, called an adrenal ade noma. Cancerous tumors of the adrenal cortex are rare, but they can cause Cushin g's syndrome as well. Occasionally, benign, nodular enlargement of both adrenal glands can result in Cushing's syndrome.
Complications If you don't receive prompt treatment for Cushing's syndrome, other complication s may occur, such as: Bone loss (osteoporosis), due to the damaging effects of excess cortisol High bl ood pressure (hypertension) Kidney stones Diabetes Frequent or unusual infection s Loss of muscle mass and strength When the cause of Cushing's syndrome is a pituitary tumor (Cushing's disease), i t can sometimes lead to other problems, such as interfering with the production of other hormones that the pituitary controls. Preparing for your appointment
You're likely to start by first seeing your family doctor or a general practitio ner. However, in some cases when you call to set up an appointment, you may be r eferred immediately to a doctor who specializes in endocrine disorders (endocrin ologist). It's a good idea to prepare for your appointment so that you can make the most of your time with your doctor. Here's some information to help you get ready, and what to expect from your doctor. What you can do
Be aware of any pre-appointment restrictions. At the time you make the appointme nt, be sure to ask if there's anything you need to do in advance to prepare for diagnostic tests. Write down any symptoms you're experiencing, including any tha t may seem unrelated to the reason for which you scheduled the appointment. For example, if you've had headaches more frequently or if you've been feeling down or more tired than usual, this is important information to share with your docto r. Also tell your doctor about changes in your physical appearance, such as weig ht gain, new acne or increased body hair. Write down key personal information, i ncluding any changes in your personal relationships and in your sex life. Let yo ur doctor know if the people closest to you have noticed that you seem irritable or that you seem to have more mood swings than in the past. Make a list of all medications, as well as any vitamins, creams or supplements, that you are curren tly taking or have used in the past. Include on your list the specific name, dos e and dates of any steroid medications you've taken in the past, such as cortiso ne injections. Take a family member or friend along, if possible. Sometimes it c an be difficult to soak up all the information provided to you during an appoint ment. Someone who accompanies you may remember something that you missed or forg ot. Write down questions to ask your doctor. Your time with your doctor is limited, so preparing a list of questions will hel p you make the most of your time together. List your questions from most importa nt to least important in case time runs out. For Cushing's syndrome, some basic questions to ask your doctor include:
What is likely causing my symptoms or condition? Are there other possible causes for my symptoms or condition? What kinds of diagnostic tests do I need? How are these tests performed? What are my treatment options? How noticeably will my ph ysical signs and symptoms improve with treatment? Will I see a difference in my appearance as well as in the way I feel? Will treatment help make me feel more e motionally stable? What long-term impact could each treatment option have? Will there be an impact on my ability to have children? How will you follow my respon se to treatment over time? Are there any alternatives to the primary approach th at you're suggesting?
I have these other health conditions. How can I best manage them together? Are t here any restrictions that I need to follow? Should I see a specialist? What wil l that cost, and will my insurance cover seeing a specialist? Is there a generic alternative to the medicine you're prescribing me? Are there any brochures or o ther printed material that I can take home with me? What Web sites do you recomm end visiting? In addition to the questions that you've prepared to ask your doctor, don't hesi tate to ask questions during your appointment at any time that you don't underst and something. What to expect from your doctor Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over an y points you want to spend more time on. Your doctor may ask: When did you first begin experiencing symptoms? Have your symptoms been continuo us, or occasional? Have they gotten worse over time? Have you noticed any change s in your sexual performance or your interest in sex? For women, has your menstr ual cycle changed, or have you stopped having your period? Have you gained weigh t? On what part of your body? Have your emotions become more unpredictable? Have you noticed that you bruise more easily, or that wounds and infections take lon ger to heal than in the past? Do you feel more physically weak than in the past? Have you developed new acne or more body or facial hair? Have you been taking a corticosteroid medication? For how long? What, if anything, seems either to imp rove or worsen your symptoms? Diagnosing Cushing's syndrome can be a long and extensive process. You may not h ave any firm answers about your condition until you've had a series of medical a ppointments. Tests and diagnosis Cushing's syndrome can be difficult to diagnose, particularly endogenous Cushing 's, because other conditions share the same signs and symptoms. Your doctor will conduct a physical exam, looking for signs of Cushing's syndrome. He or she may suspect Cushing's syndrome if you have signs such as rounding of the face (moon face), a pad of fatty tissue at the shoulders and neck (buffalo hump), and thin skin with bruises and stretch marks. If you've been taking a corticosteroid med ication long term, your doctor may suspect that you've developed Cushing's syndr ome as a result of this medication. If you
haven't been using a corticosteroid medication, these diagnostic tests may help pinpoint the cause: Urine and blood tests. These tests measure hormone levels in your urine and bloo d and show whether your body is producing excessive cortisol. For the urine test , you may be asked to collect a sample of your urine over a 24-hour period. Both the urine and blood samples will be sent to a laboratory to be analyzed for cor tisol levels. Your doctor might also recommend other specialized tests that eval uate the blood and urine to help determine if Cushing's syndrome is present and to help identify the underlying source of any excess production. These tests oft en involve measuring cortisol levels before and after stimulation or suppression with other hormone medications.
Saliva test. Cortisol levels normally rise and fall throughout the day. In peopl e without Cushing's syndrome, levels of cortisol drop significantly overnight. B y analyzing cortisol levels from a small sample of saliva collected late at nigh t, doctors can see if cortisol levels are too high, indicating a diagnosis of Cu shing's. Imaging tests. Computerized tomography (CT) scans or magnetic resonance imaging (MRI) scans can provide images of your pituitary and adrenal glands to locate abnormalities, such as tumors. As these tests help your doctor diagnose Cushing's syndrome, they may also rule out medical conditions with similar signs and symptoms. For example, polycystic ovary syndrome a hormone disorder in women with enlarged ovaries shares some of the same signs and symptoms as Cushing's has, such as excessive hair growth and irregular menstrual periods. Depression, eating disorders and alcoholism also ca n partially mimic Cushing's syndrome. Treatments and drugs Treatments for Cushing's syndrome are designed to lower the high level of cortis ol in your body. The best treatment for you depends on the cause of the syndrome . Treatment options include: Reducing corticosteroid use. If the cause of Cushing's syndrome is long-term use of corticosteroid medications, your doctor may be able to keep your Cushing's s igns and symptoms under control by reducing the dosage of the drug over a period of time, while still adequately managing your asthma, arthritis or other condit ion. For many of these medical problems, your doctor can prescribe noncorticoste roid drugs, which will allow him or her to reduce the dosage or eliminate the us e of corticosteroids altogether. Don't reduce the dose of corticosteroid drugs o r stop taking them on your own. Do so only under your doctor's supervision. Abru ptly discontinuing these medications could lead to deficient cortisol levels. Sl owly tapering off corticosteroid drugs allows your body to resume normal cortiso l production.
Surgery. If the cause of Cushing's syndrome is a tumor, your doctor may recommen d complete surgical removal. Pituitary tumors are typically removed by a neurosu rgeon, who may perform the procedure through your nose. If a tumor is present in the adrenal glands, lung or pancreas, the surgeon can remove it through a stand ard operation or in some cases by using minimally invasive surgical techniques, with smaller incisions. After the operation, you'll need to take cortisol replac ement medications to provide your body with the correct amount of cortisol. In m ost cases, you'll eventually experience a return of normal adrenal hormone produ ction, and your doctor can taper off the replacement drugs. However, this proces s can take up to a year or longer. In some instances, people with Cushing's synd rome never experience a resumption of normal adrenal function; they then need li felong replacement therapy.
Radiation therapy. If the surgeon can't totally remove the pituitary tumor, he o r she will usually prescribe radiation therapy to be used in conjunction with th e operation. Additionally, radiation may be used for people who aren't suitable candidates for surgery. Radiation can be given in small doses over a six-week pe riod, or by a technique called stereotactic radiosurgery or gammaknife radiation . In the latter procedure, administered as a single treatment, a large dose of r adiation is delivered to the tumor, and the radiation exposure to surrounding ti ssues is minimized. Medications. In some situations, when surgery and radiation don't produce a normalization of cortisol production, your doctor may advise dru g therapy. Medications to control excessive production of cortisol include ketoc onazole (Nizoral), mitotane (Lysodren) and metyrapone (Metopirone). Drugs also a re sometimes prescribed before surgery for people who are very sick. Doing so ma y improve their signs and symptoms and minimize their surgical risk. In some cas es, the tumor or its treatment will cause other hormones produced by the pituita ry or adrenal gland to become deficient and your doctor will recommend hormone r eplacement medications. If none of these treatment options is effective, your doctor may recommend surgi cal removal of your adrenal glands (bilateral adrenalectomy). This procedure wil l cure excess production of cortisol. However, your ACTH levels will remain high , possibly causing excess pigmentation of your skin. Left untreated, Cushing's s yndrome can lead to death. However, most often, treatments improve signs and sym ptoms and normalize cortisol levels.