Cushing syndrome is a disorder with physical and mental changes that result from having too much cortisol in the blood for a long period of time.
Important Symptoms of Cushing’s Syndrome
Wired at night
Trouble sleeping-trouble falling asleep or frequent awakenings
Severe fatigue-new onset
Abrupt weight gain-without other cause such as decreased activity or depression
Decreased ability to exercise
Cognitive changes- “brain fog”
Decreased libido-low interest in sex
Symptoms of adrenal insufficiency-joint pains, can’t get out of bed, nausea and vomiting
Depression, anxiety, mood-swings
Important Signs of Cushing’s Syndrome
Round, red face
Extra hair growth
Loss of hair on head
How Is Cushings Diagnosed
Careful history and physical
Change in weight and body habitus
Look at old pictures
Not all patients have all signs and symptoms, especially “early” and “episodic” patients.
Important to diagnose early before devastating sequelae develop.
Initial diagnosis most difficult aspect of Cushing’s syndrome.
“Gestalt” with as much information as possible
Episodic Cushing’s common, so one positive test may be worth more than 10 negative tests
Best tests are 24 hour urines for urinary free cortisols (UFC) and 17-hydroxysteroids (17-OHS, only done at Labcorp and 11 PM-12 midnight salivary cortisols are the best tests and multiple tests should be done to catch “highs”
Midnight serum cortisols are also good and can be done in hospitals or emergency rooms.
Dr. Friedman does not recommend the dexamethasone suppression test or the DDAVP stimulation test. Too many patients who end up having Cushing’s disease suppress to dexamethasone and have a normal response to DDAVP.
Medications to treat Cushing’s
Endocrinologist, Dr. Friedman, often uses medications to treat Cushing’s syndrome. Unlikely other doctors that may take a long time to diagnose a patient with Cushing’s and then send the patient directly to surgery, Dr. Friedman puts all patients that he has diagnosed with Cushing’s syndrome. on cortisol-lowering medications prior to pituitary surgery. He does that for 4 reasons:
Medications that lower cortisol can get the patient feeling better right away
The medications can determine if the patients’ symptoms are due to high cortisol. If the Cushing’s symptoms resolve with medications, they will likely resolve with pituitary surgery. If they do not resolve, the patient is unlikely to improve with surgery and the diagnosis of Cushing’s may need to be re-assessed.
Lowering cortisol before surgery decreases the risks of surgery, which includes blood clots and infections.
Lowering cortisol before surgery decreases the drop in cortisol after successful surgery, so cortisol withdrawal symptoms are less.
Dr. Friedman especially recommends ketoconazole; an in-depth article on ketoconazole can be found on goodhormonehealth.com. He also uses Isturisa (osilodrostat), often in combination with ketoconazole. Many patients feel so well on the medications, they don’t want surgery. Dr. Friedman has patients that have done well on ketoconazole for over 10 years.
Dr. Friedman has the most experience of using medications to treat Cushing’s disease of any Endocrinologist in the country.
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Dr. Friedman’s web site does not offer medical advice. These materials are offered for information purposes only. Do not act or rely upon information from goodhormonehealth.com without seeking professional medical advice. Additionally, the transmission of information from the web site, goodhormonehealth.com to you, is not intended to create nor does create a physician-patient relationship between you and Dr. Friedman.