The case
A 40-year-old woman complained of new facial hair and menstrual irregularity. She appeared to be a little hump-shouldered and was found to have new onset hypertension and new onset diabetes. On the top of the possible diagnoses list was Cushing’s Syndrome.
Cortisol is a glucocorticoid, a hormone usually secreted by the adrenal glands. The disease condition of excess cortisol is called Cushing’s Syndrome. The signs and symptoms of Cushing’s Syndrome include:
- High blood pressure
- Weakness and fatigue
- Anxiety and/or depression
- Weak bones
- Other changes in the body
Body Changes in Cushing’s Syndrome
Changes in the body are caused by an unusual accumulation of body fat and by changes in blood vessel strength. Fat accumulates high in the back, behind the neck, and resembles a buffalo hump. There also may be more fat in the face. The skin may have new stretch marks and prominent blood vessels.
Effects on Women
While cortisol originally was found to affect how the body deals with sugar (hence the gluco- prefix in glucocorticoid), it also has some male hormone effect. In women, this can cause hair to grow on the face and chest (hirsutism), and can disrupt menstrual cycles.
Effects on Men
Male hormone effect notwithstanding, men may develop erectile dysfunction and lose interest in sex. They may also become bald.
What Causes the Excess Cortisol?
Dr. Cushing, for whom the syndrome is named, described in 1932 a pituitary tumor that produced ACTH. ACTH stimulates the adrenals glands to produce cortisol. (See figure) When the excess cortisol is caused by a pituitary tumor, the condition is often called Cushing’s Disease.
Less commonly, the excess cortisol comes about from another disease, and the condition is simply called Cushing’s Syndrome. A person with the syndrome is often labeled “Cushionoid.”
Causes of Cushing’s Syndrome include:
- A tumor in the pituitary in the brain that secretes ACTH (original Cushing’s Disease)
- A tumor of the adrenal gland that secretes cortisol directly
- Another tumor, often a cancer. Lung cancers are often the source. The tumor produces ACTH for some reason. This is called “ectopic ACTH” because it comes from a place outside the pituitary. When it comes from a cancer, it’s called a paraneoplastic effect of the cancer.
The most common cause of Cushing’s Syndrome probably is medicinal use of steroids. Cortisol is used to treat rheumatoid arthritis and related diseases, some lung diseases, and several other conditions. (It is important to note that cortisol does not build strength or endurance, so it is not likely to be abused by athletes; they would probably choose an androgen steroid.)
Diagnosis and Treatment of Cushing’s Disease
Several blood and urine tests are available. Because cortisol blood levels normally vary during the day, often a midnight blood test is used. A midnight saliva test is also available. Urine tests usually require a 24-hour collection.
If Cushing’s Syndrome is confirmed by tests, then the next step is to determine the source of the excess cortisol. This becomes the specialist’s challenge. Treatment depends on the cause of the problem.
Birth control pills that contain estrogen can produce a high total blood cortisol level, since estrogen increases the cortisol binding protein, but usually the free, or active, cortisol level is normal. This is called "pseudo-Cushing’s."
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James Cooper - I'm on the faculty of a health science department at a large university. Most of my articles derive from conferences or presentations ...
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