Cushings Syndrome

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Cushing’s syndrome (also known as hypercortisolism) develops when the body is exposed to high levels of cortisol for an extended period of time. Cortisol is a hormone produced by the adrenal gland, and is released in response to stress. It’s primary function is to increase blood sugar and promote metabolism. Cushing’s syndrome most often results from the use of oral corticosteroids (such as prednisone) to treat inflammatory conditions such as rheumatoid arthritis, lupus, and asthma. It can also occur when the body naturally produces too much cortisol. This can happen as a result of a tumor in the pituitary gland, a diseased adrenal gland, or through a rare inherited condition that leads to the development of Cushing’s syndrome. Cushing’s syndrome can also arise following repeated injections of corticosteroids to treat joint pain and back pain.

Tell-tale signs of Cushing’s syndrome include a fatty lump between the shoulders, round face, and pink or purple stretch marks on the skin. High blood pressure, loss of bone, and diabetes can also result. The primary symptoms of Cushing’s syndrome include acne, weight gain, and deposits of fatty tissue around the midsection and upper back, as well as thinning skin that easily bruises. In addition, individuals affected by Cushing’s syndrome may find that cuts, insect bites, and infections take longer to heal. General signs and symptoms also include fatigue, muscle weakness, depression and anxiety, emotionality, cognitive difficulties, and headache. There are also gender-specific side effects associated with Cushing’s syndrome. For example, women tend to have thicker and more visible body and facial hair (a condition known as hirsutism), and can have irregular or nonexistent menstrual cycles. Men with Cushing’s syndrome may suffer from decreased libido, impaired fertility, and erectile dysfunction.

If Cushing’s syndrome is not treated, numerous complications can arise, many of which are severe. Bone loss (also known as osteoporosis) can develop and lead to bone fractures, particularly in the ribs and feet. High blood pressure, diabetes, frequent infections, and loss of muscle mass and strength are also potential side effects of untreated Cushing’s syndrome.

The diagnosis of Cushing’s syndrome is difficult due to the fact that many other conditions share its symptoms and signs. A physical exam is usually performed by a physician to look for the fatty tissue deposits on the body, and if the patient has a recent history of taking corticosteroid medications, urine, blood, and saliva tests may be useful to help measure levels of cortisol. Additionally, computed tomography (CT scan or “CAT scan”) and magnetic resonance imaging (MRI) can be used to visualize the pituitary and adrenal glands and look for possible tumors. CT and MRI are non-invasive imaging techniques that provide detailed images of areas inside the body.

Treatment for Cushing’s syndrome is most successful when it is tailored to address the specific cause. For example, an individual who has developed Cushing’s syndrome as a result of chronic corticosteroid use may be able to control the condition by gradually lowering the dose of their corticosteroid over time, and substituting the corticosteroid with a non-steroidal medication. For tumor-related Cushing’s syndrome, surgery to remove the tumor  will likely be required, and individuals will typically need to take cortisol replacement medications for some time following surgery. In addition to medicinal and surgical treatments, a number of lifestyle modifications can be helpful as supportive care during the recovery from Cushing’s syndrome. Physical activity should be gradually reintroduced at a slow and steady pace, and a healthy diet is necessary to help shed extra weight caused by Cushing’s syndrome. In addition, individuals should be certain to have adequate intakes of calcium and vitamin D to promote bone strength and rebuilding. Depression is also common with Cushing’s syndrome and should be managed appropriately.

Cushing’s Syndrome and Fibromyalgia

Fibromyalgia and Cushing’s syndrome share a number of overlapping signs and symptoms, including fatigue, muscle weakness, depression and anxiety, emotional swings, cognitive difficulties, and headache. In addition, disrupted menstrual cycles are also a common symptom associated with both conditions. These commonalities can make differentiating between the two conditions difficult during the diagnostic process, particularly in cases where there is no obvious glandular tumor to blame. Additionally, many individuals with fibromyalgia-like symptoms suffer from chronic pain and arthritis-like conditions, and as a result may receive treatment with oral corticosteroids or corticosteroid injections for joint inflammation and pain. Therefore, individuals with fibromyalgia who are treated long-term with corticosteroids run the risk of developing Cushing’s syndrome. Such situations underscore the need for fibromyalgia patients to diligently monitor and track all treatments, medications, and therapies. In doing so, it will easier to identify new symptoms that arise, or existing symptoms that worsen, and relate them to a specific causal factor.

Unfortunately, there is a lack of scientific research available regarding a specific relationship between Cushing’s syndrome and fibromyalgia. One case report does exist detailing a patient who developed fibromyalgia-like symptoms following treatment for Cushing’s syndrome (Baldini et al., 2005).  An earlier case report also describes the development of severe fibromyalgia that developed in a patient following surgical removal of the pituitary gland for the treatment of Cushing’s syndrome. The authors report detailed that the patient met American College of Rheumatology (ACR) criteria for the diagnosis of fibromyalgia, having 12 of 18 tender points upon clinical examination. The authors also suggested that the removal of the pituitary gland may have disrupted the patient’s natural endorphin production and ability to regulate pain, thereby leading to the development of fibromyalgia (Disdier et al., 1991). Endorphins are certain hormones produced within the body that act as the body’s natural pain killers.

There is a larger body of research regarding cortisol levels in fibromyalgia patients in general. Although previous research on this topic is questionable due to difficulties inherent in measuring cortisol levels consistently across studies, recent studies have found that fibromyalgia patients on average have low levels of cortisol (Riva et al., 2010; Riva et al., 2012; Izquierdo –Alvarez et al., 2008). Along the lines of the theory put forth by Disdier et al., (1991), which suggests that the disruption of endorphin production may somehow predispose an individual to fibromyalgia, numerous studies have investigated the function of what is known as the “hypothalamic-pituitary-adrenal axis”, or HPA axis. These three glands – the hypothalamus, pituitary, and adrenal – form a major part of the neuroendocrine system, which controls the body’s response to stress and helps to regulate mood, emotions, energy storage, and the immune system. Studies have found that disruptions in hormone production by the HPA axis, specifically cortisol, may be related to the development of depression in fibromyalgia patients, and that overall HPA dysfunction in fibromyalgia patients may also result in other signs and symptoms associated with the condition (Wingenfeld et al., 2010; Gur et al., 2004; Catley et al., 2000; Curtis et al., 2011).

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 references

1.        Baldini M, Orsatti A, Cantalamessa L. Fibromyalgia symptoms after treatment for Cushing’s syndrome. Clin Exp Rheumatol. 2005;23(4):552.

2.        Catley D, Kaell AT, Kirschbaum C, Stone AA. A naturalistic evaluation of cortisol secretion in persons with fibromyalgia and rheumatoid arthritis. Arthritis Care Res. 2000;13(1):51-61.

3.        Curtis K, Osadchuk A, Katz J. An eight-week yoga intervention is associated with improvements in pain, psychological functioning and mindfulness, and changes in cortisol levels in women with fibromyalgia. J Pain Res. 2011;4:189-201.

4.        Disdier P, Harle JR, Brue T, Jaquet P, Chambourlier P, Grisoli F, Weiller PJ. Severe fibromyalgia after hypophysectomy for Cushing’s disease. Arthritis Rheum. 1991;34(4):493-495.

5.        Gur A, Cevik R, Sarac AJ, Colpan L, Em S. Hypothalamic-pituitary-gonadal axis and cortisol in young women with primary fibromyalgia: the potential roles of depression, fatigue, and sleep disturbance in the occurrence of hypocortisolism. Ann Rheum Dis. 2004;63(11):1504-1506.

6.        Izquierdo-Alvarez S, Bocos-Terraz JP, Bancalero-Flores JL, Pavón-Romero L, Serrano-Ostariz E, de Miquel CA. Is there an association between fibromyalgia and below-normal levels of urinary cortisol? BMC Res Notes. 2008;1:134.

7.        Riva R, Mork PJ, Westgaard RH, Lundberg U. Comparison of the cortisol awakening response in women with shoulder and neck pain and women with fibromyalgia. Psychoneuroendocrinology. 2012;37(2):299-306.

8.        Riva R, Mork PJ, Westgaard RH, Ro M, Lundberg U. Fibromyalgia syndrome is associated with hypocortisolism. Int J Behav Med. 2010; 7(3):223–233.

Wingenfeld K, Nutzinger D, Kauth J, Hellhammer DH, Lautenbacher S. Salivary cortisol release and hypothalamic pituitary adrenal axis feedback sensitivity in fibromyalgia is associated with depression but not with pain. J Pain. 2010;11(11):1195-1202.

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