Cushing Syndrome

Cushing syndrome or hypercortisolism is a hormonal disorder that develops due to high level of a hormone called cortisol for a long period of time.

High levels of cortisol can result from either excess cortisol production in your body or use of oral corticosteroid medication.

The typical symptoms of Cushing syndrome include a hump on upper back, a round face, and pink or purple stretch marks on your skin.

Cushing syndrome can also cause hypertension, osteoporosis (bone loss) and sometimes diabetes. Treatments for Cushing syndrome aim at normalizing cortisol production and relieving symptoms. You are likely to recovery faster if your treatments start earlier.

The signs and symptoms of Cushing syndrome can vary depending on the levels of excess cortisol. Gradual weight gain and changes in skin are commonly observed, which include:

• Weight gain and fat accumulation around your abdomen and upper back (buffalo hump)
• Rounded face also called moon face, caused by fat accumulation in the face
• Pink or purple stretch marks (striae) on the skin of the abdomen, thighs, breasts and arms
• Skin thinning and easy bruising
• Delayed wound healing
• Acne

Women with Cushing syndrome may experience:

• Hirsutism (abnormal facial and body hair growth)
• Irregular or missed menstrual periods

Men with Cushing syndrome may experience:

• Low sex drive
• Fertility problems
• Impotence

Other signs and symptoms include:

• Extreme tiredness
• Weak muscles
• Mood problems such as depression, anxiety and irritability
• Uncontrolled emotions
• Impaired thinking ability (cognitive problems)
• Hypertension
• Headache
• Fragile bones prone to fractures

When to see a doctor?

Visit your doctor if you experience signs and symptoms indicative of Cushing syndrome. Remember, if you are taking corticosteroids for other medical conditions, your chances of developing Cushing syndrome are high.

Cushing syndrome is caused by high level of cortisol in your body. Cortisol, also called stress hormone, is secreted by adrenal glands and helps to carry out numerous functions, ranging from regulation of blood pressure to metabolism of proteins, carbohydrates and fats. Higher levels of corticosteroids for prolonged period can cause Cushing syndrome.

Two types of Cushing syndrome can develop from higher cortisol levels in the body, they are:

1. Exogenous Cushing syndrome, in which the symptoms are caused by intake of high doses of corticosteroid medications such as prednisone.Corticosteroids can be taken by mouth to treat inflammatory conditions like rheumatoid arthritis or to suppress your immune system after an organ transplant. These steroids can also be given by injection such as in joint pain and bursitis, by inhalation in asthma or applied on the skin in eczema. The risk of developing Cushing syndrome through inhaled steroids and steroid skin creams is low.

2. Endogenous Cushing syndrome, in which the symptoms are caused by overproduction of the hormone due to excess secretion of a hormone regulating cortisol secretion, adrenocorticotropic hormone (ACTH). Various conditions that can cause this type of Cushing syndrome are:

• Tumor of pituitary gland (pituitary adenoma): A noncancerous (benign) tumor of the
• pituitary gland results in overproduction of ACTH which causes adrenal glands to secrete excess cortisol. It mostly occurs in women.
• An ectopic ACTH-secreting tumor: Rarely, Cushing syndrome can also result due to overproduction of ACTH by atypical tumors in the lungs, thyroid or thymus gland.
• A primary adrenal gland disease: In few cases, Cushing syndrome develops due to adrenal glands disorder. An adrenal adenoma, non-cancerous tumor of adrenal cortex, is the most common adrenal gland disorder. A rare cancerous tumor of the adrenal cortex (adrenocortical carcinomas) can cause Cushing syndrome as well.
• Familial Cushing syndrome: In few cases, inheritance of certain genes causes tumors on one or more endocrine glands, thereby increasing cortisol level and resulting in Cushing syndrome.

Your family doctor will recommend you to an endocrinologist (who treats endocrinal disorders).

How to prepare yourself for the visit?

Getting prepared for the visit can optimize the therapy and help make the visit more fruitful. List out all the symptoms. Write down your key medical information. Write down the names of all your medications (including corticosteroids), vitamins or supplements.

Ask a friend or a family member to accompany you during the visit.

Make a list of the questions to ask your doctor. Some typical questions can be:

• What could be causing my symptoms?
• What diagnostic tests do I need?
• What are my treatment options and which one is more likely to relieve my symptoms?
• Will the treatment improve my appearance and emotions?
• Will the treatment affect my ability to have children?
• What about the follow-ups to monitor my progress?
• Do I need to follow any restrictions?
• Should I see a specialist?

What your doctor wants to know?

A clear talk with your doctor can optimize the therapy and improve the outcomes. Prepare yourself to answer some essential questions from your doctor. Your doctor might ask you typical questions like:

• When did the symptoms start appearing and how severe are they?
• Do your symptoms occur continuously or come and go?
• Have your symptoms worsened over time?
• Are there any changes in your sexual performance or your sex drive?
• For women, is your menstrual cycle normal?
• Have you noticed changes in your weight?
• Do you experience difficulty controlling your emotions?
• Do you bruise more easily?
• Do your wounds heal more slowly than in the past?
• Have you experienced muscle weakness during your normal activities like walking?
• Are you having new acne or more body or facial hair recently?
• Have you been on corticosteroid therapy? For how long?
• Does anything improve or aggravate your symptoms?

There is no diagnostic test for Cushing syndrome. So, it can be quite difficult to confirm the diagnosis of Cushing syndrome.

Your doctor will diagnose the disease by physical examination, and evaluating your symptoms. S/he can suspect Cushing syndrome if you have been taking corticosteroid medications for a prolonged time.

If your Cushing syndrome isn’t caused by corticosteroid medication, following tests may be performed:

• Urine and blood tests: Urine and blood tests are performed to check if there is excess level of cortisol. Specialized urine and blood tests may be ordered to detect the cause of Cushing syndrome.
• Saliva test: In healthy individual, secretion of cortisol rises in the morning and drops significantly in the evening. A sample of saliva is collected late at night and tested to check if cortisol levels are high.
• Imaging tests: Computerized tomography (CT) scans or magnetic resonance imaging (MRI) scans help detect abnormalities in your pituitary and adrenal glands.

Your doctor may perform tests to see if your symptoms are caused by other medical conditions.

Treatments for Cushing syndrome aim to bring your cortisol to normal level. Treatments for Cushing syndrome are: 

Reducing corticosteroid use: This approach helps to reduce the signs and symptoms if Cushing syndrome is caused by intake of corticosteroid medications.

• Surgery: Surgery can remove a tumor that is causing Cushing syndrome. After the surgery, you may need medications to maintain the normal amount of cortisol. If your body starts producing adrenal hormone on its own, your doctor will taper off the medications. In some cases, you may need medication throughout your life.
• Radiation therapy: It is opted if complete tumor cannot be removed by surgery or surgery cannot be performed. Radiation is given either in small doses for six weeks or in large doses as a single dose by a technique called stereotactic radiosurgery (Gamma Knife surgery).
• Medications: Medications such as ketoconazole, mitotane and metyrapone are given when both surgery and radiation fail to treat your condition. Medications may be given prior to surgery to reduce signs and symptoms, and the risk associated with surgery. Mifepristone which blocks the effect of cortisol on your tissues, may be given to people with type II diabetes or glucose intolerance.
• Bilateral adrenalectomy (removal of both adrenal glands) may be opted if all other treatments fail.

Following tips may be helpful to cope up with cushing syndrome:

• Don’t hurry when increasing the level of activities. You may choose the exercise which is appropriate for your condition.
• Eat healthy: Focus on nutrient-rich and wholesome foods to lose extra weight. Ensure that your body is getting enough calcium and vitamin D to strengthen your bones.
• Keep an eye on your mental health: Cushing syndrome like any other chronic disease can cause depression. Immediately visit your doctor if you are depressed or stressed out because of your condition.
• Gently soothe aches and pains: Hot baths, massages and low-impact exercises, such as water aerobics and tai chi, can reduce muscle and joint pain experienced during Cushing syndrome recovery.
• Train your brain: Brain training exercises such as math problems and crossword puzzles, can improve your cognition.
• Join a support group in your community or online, if any. Talk to your doctor to find a support group near you.

There are several complications associated with cushing syndrome, which include:

• Bone loss (osteoporosis) which makes your bones more prone to fracture
• High blood pressure (hypertension)
• Diabetes
• Recurrent infections
• Loss of muscle mass and strength
• If Cushing syndrome is caused by a pituitary tumor (Cushing disease), it may interfere with production of other hormones regulated by the pituitary gland.