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  1. #16
    Thanks to God for Lily! REW's Avatar
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    I have to say that I agree with seeing a specialist - if you can get in to one without having some of the tests first. I only say this because my Mom's endo NEVER considered she had Cushings and she finally got diagnosed with it because her DERMATOLOGIST wanted her to do a first test. Mom has the hump, tearing skin, bruising, weight gain, anixiety, cataracts 6 years ago, and the list goes on and on. Thankfully she lives in Los Angeles and has access to a variety of specialists and is leaving her endo and will be seen at Cedars Sinai that has a well known pituitary center.

    Good luck!

  2. #17
    Registered User VRSweeney's Avatar
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    Like REW said, there are a lot of other symptoms besides a hump, acne and stretch marks. Try to not feak out. You should get it checked out, but chances are you don't have Cushing's.
    Vicki (37) & Gene (36)


    Cycle #1 of Met. & Clomid : (1/08) Prov.(1500 mg Met., Clomid 50 mg) CD 2-6, (++ OPK on CD 26, tons of EWCM on CD 27)

    BFP on 2/9 10 DPO
    2/13 Beta 110; P4=51
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    U/S 6w , HB 102!
    U/S 10 w, HB 160

    7/30 - It's a BOY!(Daniel)

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  3. #18
    So in Love with my Kids! sleepy_214's Avatar
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    http://www.postgradmed.com/issues/19...8/hasinski.htm
    Hypercortisolism

    Cushing's syndrome is defined as any chronic increase in glucocorticoid activity. By far the most common cause is prolonged use of glucocorticoid agents for treatment of chronic inflammatory diseases (eg, rheumatoid arthritis) or after organ transplantation. Other possible causes include pituitary adenomas (Cushing's disease), adrenal adenomas or carcinomas, and ectopic production of corticotropin-releasing hormone or corticotropin. Use of corticosteroids or chronic use of inhaled corticosteroids or corticosteroid creams must also be considered.

    As with adrenal insufficiency, Cushing's syndrome may be elusive, and a high level of suspicion is needed. Symptoms can include worsening obesity, new-onset hypertension, skin changes (eg, easy bruising, striae), poor wound healing, facial plethora, hirsutism, acne, muscle weakness and wasting, peripheral edema, and neuropsychiatric changes (eg, depression, mania).

    Cushing's syndrome can be classified as corticotropin-dependent or corticotropin-independent (table 1). Corticotropin-dependent Cushing's syndrome is further classified as caused by pituitary adenoma (Cushing's disease) or by ectopic production of corticotropin or corticotropin-releasing hormone. Corticotropin may be produced ectopically by malignancy (ie, lung carcinoma, renal-cell carcinoma), as is the case in about 80% of patients, or by other tumors, such as carcinoid tumors in the lung, pancreas, or thymus (1,6).

    Table 1. Causes of Cushing's syndrome

    Corticotropin-dependent

    Pituitary adenoma (Cushing's disease)

    Ectopic corticotropin production from carcinoma (eg, lung, breast, renal-cell)

    Ectopic corticotropin-releasing hormone production from carcinoid tumors (eg, chest, thymus)

    Corticotropin-independent

    Adrenal adenoma

    Adrenal carcinoma

    Micronodular dysplasia

    Macronodular hyperplasia

    Iatrogenic causes

    Corticotropin-independent Cushing's syndrome is caused by autonomous production of cortisol. Possible sources include adrenal adenomas, adrenal carcinomas, primary pigmented nodular adrenal dysplasia (micronodular dysplasia), macronodular hyperplasia, and other, relatively rare, disorders.

    Screening tests
    The first step in evaluating Cushing's syndrome is to determine whether hypercortisolism is present. The most convenient screening procedure is the overnight dexamethasone suppression test, in which 1 mg of dexamethasone is given orally at bedtime (usually between 10 and 11 pm). A fasting blood sample is drawn when the patient arises the next morning (preferably by 8 am), and cortisol is measured. The fasting plasma cortisol level should be less than 5 micrograms/dL, although some authorities believe that a level of less than 3 micrograms/dL is more sensitive and specific (7). A level greater than 5 micrograms/dL warrants further testing.

    A 24-hour urine collection for urinary free cortisol is also an excellent screening test. High-performance liquid chromatography enhances conventional protein-binding assays and also increases sensitivity and specificity (7). False-negative results may occur because of inadequate collection, daily fluctuations in cortisol levels, or abnormalities caused by other medications the patient may be using. Therefore, at least three samples should be obtained. If all three samples show normal cortisol levels, Cushing's syndrome can be ruled out. If any of the three values is abnormal, further testing is warranted (6,8).

    If either the overnight dexamethasone suppression test or any of the 24-hour urine evaluations are abnormal, false-positive results and pseudo-Cushing's syndrome need to be considered. Traditionally, a low-dose (2 mg/day) dexamethasone test has been used. High-dose (8 mg/day) dexamethasone suppression is used to distinguish Cushing's disease (pituitary) from other causes of Cushing's syndrome (table 2).

    Table 2. Low-dose followed by high-dose dexamethasone suppression test

    Day 1
    Obtain baseline plasma cortisol and corticotropin values
    Begin baseline 24-hr urine collection for free cortisol and 17-OHCS

    Day 2 (low-dose dexamethasone suppression)
    Complete baseline 24-hr urine collection
    Start dexamethasone, 0.5 mg orally every 6 hr

    Day 3
    Continue dexamethasone, 0.5 mg orally every 6 hr
    Begin second 24-hr urine collection for free cortisol and 17-OHCS

    Day 4 (high-dose dexamethasone suppression)
    Measure plasma cortisol
    Complete second 24-hr urine collection
    Begin dexamethasone, 2 mg orally every 6 hr

    Day 5
    Continue with dexamethasone, 2 mg orally every 6 hr
    Begin third 24-hr urine collection for free cortisol and 17-OHCS

    Day 6
    Complete third 24-hr urine collection
    Measure plasma cortisol and corticotropin

    17-OHCS, 17-hydroxycorticosteroids.

    For the low-dose dexamethasone suppression test, baseline plasma cortisol and corticotropin levels are measured and a 24-hour urine collection is made on day 1 to establish free cortisol and 17-OHCS levels. Beginning on day 2, after the urine collection is completed, 0.5 mg of dexamethasone is given orally every 6 hours for 8 doses (2 days). On day 3, a second 24-hour urine sample is collected, and free cortisol and 17-OHCS values are measured again. The high-dose dexamethasone suppression test starts on day 4. After the second 24-hour urine collection is completed, the dexamethasone dose is increased to 2 mg orally every 6 hours for 8 doses (2 days). On day 5, dexamethasone is continued and a third 24-hour urine collection is begun. Finally, on day 6, plasma cortisol and corticotropin are measured again. The third 24-hour urine sample can be held, pending the results of the second 24-hour sample, and urine cortisol and 17-OHCS levels can be determined if results of the second 24-hour urine study were abnormal.

    In patients who have normal cortisol metabolism and those with pseudo-Cushing's syndrome, the second 24-hour urine collection (low-dose dexamethasone suppression) shows urinary free cortisol levels of less than 4 mg per 24 hours, and the plasma cortisol level is less than 3 micrograms/dL. The high-dose dexamethasone test is then used to distinguish Cushing's disease from other causes of Cushing's syndrome. In Cushing's disease, the third 24-hour urine collection shows a 90% decrease in cortisol from baseline and a 64% decrease in 17-OHCS (8-10). Lesser degrees of suppression indicate nonpituitary-dependent Cushing's syndrome (eg, adrenal adenoma or carcinoma, ectopic corticotropin production).

    Administration of low- and high-dose dexamethasone to suppress cortisol production is cumbersome and may be difficult to complete properly. A high-dose overnight dexamethasone suppression test is simpler and may prove equally effective. With this test, baseline plasma cortisol and corticotropin levels are obtained from the fasting patient (by 8 am), 8 mg of dexamethasone is given orally at bedtime, and cortisol levels are remeasured the next morning. In patients with Cushing's disease, the follow-up cortisol values usually decrease by 50% from the baseline (8). The high-dose overnight test has been favorably compared with the standard high-dose dexamethasone suppression test (9). Some tumors (ie, carcinoids) cause some degree of suppression on dexamethasone testing.

    Another test using synthetic corticotropin-releasing hormone may be able to differentiate Cushing's disease from other causes of Cushing's syndrome. In Cushing's disease, there is a paradoxical increase in the level of corticotropin after administration of corticotropin-releasing hormone. However, considerable overlap is seen among patients with normal levels and those with Cushing's syndrome. Therefore, this test should not be used routinely. Corticotropin levels should be measured by immunoradiometric assay, which has greater specificity and sensitivity, although this assay cannot detect an unusual type of corticotropin (ie, "big" corticotropin), which may also have biologic activity (8).

    Scanning techniques
    Appropriate radiologic and nuclear medicine studies should be used as directed by the biochemical studies. MRI of the pituitary, with and without gadolinium, is superior to CT scanning. Nonetheless, between 40% and 50% of pituitary tumors are missed by MRI in patients with Cushing's disease (6,8). CT scanning is preferred for viewing the adrenal glands and chest. However, adrenal CT scans must be interpreted cautiously, since 2% to 15% of patients have nonfunctioning adenomas (incidentalomas) (6,11). Iodo-seleno-cholesterol scans are used to evaluate synthetic function within the adrenal gland. Octreotide scans are used to localize ectopic corticotropin-producing tumors (carcinoids), many of which have somatostatin receptors (6).

    When Cushing's disease is confirmed, inferior petrosal sinus sampling may help localize the cause. The inferior petrosal sinuses are selectively and simultaneously catheterized, and baseline blood samples for corticotropin are simultaneously obtained from both sinuses as well as peripherally. Corticotropin-releasing hormone (100 micrograms or 1 microgram/kg of body weight) is injected, and blood samples for corticotropin are drawn from the sinuses and peripherally at 2, 3, 5, and 10 minutes. Ratios are established between inferior petrosal sinus levels and peripheral corticotropin levels. A ratio greater than 2.0 is consistent with Cushing's disease. An interpetrosal gradient (eg, right versus left) greater than 1.2 after corticotropin-releasing hormone injection predicts the location of a lesion in 70% to 80% of patients (6,8,9). However, the procedure may be complicated by cavernous sinus thrombosis, infection, hemorrhage, and brainstem ischemia (8,9,12). Because of its complexity and risk for complications, inferior petrosal sinus sampling should be performed only in centers with considerable expertise.
    Summary

    The rapid cosyntropin stimulation test offers a simple means for detecting adrenal insufficiency. In contrast, assessment of suspected hypercortisolism (Cushing's syndrome) is difficult because cortisol levels fluctuate with intermittent release of corticotropin from the pituitary or from tumors. Also, a number of medications affect cortisol levels, leading to false-positive or false-negative results. The classic low-dose followed by high-dose dexamethasone test is cumbersome, and other, simpler studies, such as the overnight high-dose dexamethasone suppression test, may prove more practical and cost-effective. With both high and low levels of adrenal glucocorticoids, awareness and early recognition of the symptoms are important. An endocrinologist should be consulted when the overnight dexamethasone suppression test or the 24-hour urine cortisol collection is abnormal or if clinical suspicion is high despite normal results on screening tests.
    6/08 Dx with Cushing's Disease , surgery date TBA
    Thanks for the advice all these years and good luck to all.

  4. #19
    Registered User PCOSBill's Avatar
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    Following this with interest... I am doing my 24 hour urine test today. (fun fun)

    I don't *look* terribly Cushingoid, or really overly PCOSish. I do have (a lot of) weight around the mid-section, stretch marks (hooo boy), bruise easily, and flaming red face from Hades. I have hair in odd places, but doctors assume I don't (don't they realize I can use a razor as well as my husband?)

    But more telling, for my doctor, was the other issues I have... Bone, joint, leg, hip and back pain, with no known cause. They thought it was fibro, but I don't have tender points... I just hurt in the lower half of my body. I get wicked arm fatigue (combing my hair is hard because my arms get heavier and heavier). Never mind the whole body, crushing, absolutely all encompassing fatigue. I do have weird IR problems, but that could be the PCOS as well as anything else.

    I suggested the urine test to my GP after talking with my gyn specialist, who dx'd the PCOS. The more I read on PCOS, the more I realized this has less to do with my reproductive organs and more to do with my endocrine system. And Cushings actually explains a lot more of my symptoms than PCOS does. I don't know as I really have Cushings, I doubt it, but I thought it was probably a good thing to suggest to my doctor.

    My GP asked why I wanted it done, and I told her my reasoning, and she looked up adrenal problems... And found that yes, I do fit the bill to some degree, and since they've checked EVERYTHING else looking for the fatigue source... she thought it was a logical next step to try this.

    It's weird to suggest stuff to your doctor... I always feel like they're going to think I'm just like... I don't know... sitting there dreaming stuff up. But I'm lucky in that mine's very open to suggestion, and she even said, "Good for you! I think this test is a good idea. I'm surprised we haven't done one before!"

    It's good to know too that sometimes multiple 24 hour urines are needed... I might do another when this comes back regardless of results.

    PCOSBill

  5. #20
    Pain is a Killjoy Betwixt's Avatar
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    Yea, I don't have joint pain, per se, but pressure point pain. Like, SEVERE. When the massage therapist would push on it, I would shriek, it hurt that bad. Of course no one will say what it could be. I feel like a hypochondriac half the time because I match huge lists of symptoms.

  6. #21
    So in Love with my Kids! sleepy_214's Avatar
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    PCOSBill, if this is helpful to you please read through this study. If you see it mentions the statistics on the possibility of not only false positives, but false negatives of 24 UFC's. The more studies regarding diagnosis you can find, the more you see that it is important to have multiple tests, but multiple urine, timed serums, suppression, and possibly imaging to help rule out or confirm a diagnosis of Cushing's.

    Here is a quote from another abstract:
    "CONCLUSIONS

    PCO and PCOS are common in women with Cushing's syndrome; women with Cushing's syndrome and only moderately elevated cortisol secretion maintain gonadotrophin stimulation to the ovary with normal oestradiol levels, in contrast to women with Cushing's syndrome and higher cortisol secretion who develop hypogonadotrophic hypogonadism. However, even in the latter group, high ovarian volumes were maintained and some had ovarian morphology suggestive of PCO."

    This post is only meant to show what I have read, in part, for research I have done for MYSELF... It is not meant to be alarming or a scare tactic... just to help inform those that may wish to pursue this seriously and further.

    I wish you all luck.
    6/08 Dx with Cushing's Disease , surgery date TBA
    Thanks for the advice all these years and good luck to all.

  7. #22
    Registered User PCOSBill's Avatar
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    Thanks sleepy. I'm going to bring up the suggestion of multiple tests before I drop off my urine tomorrow ("Here, Dr. B, a present for ya!") so that she doesn't think, if I mention a retest at the time she gives me the results, that I'm just not satisfied with the answer the test gives, be it positive or negative.

    Thanks again

  8. #23
    Registered User yw23's Avatar
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    i too, thought i had cushing, i have the hump, but i went to my endo, and i didn't tell him i had pcos, because the symptoms are so much alike, they ran tests on me it all came back negative..and he too said i had pcos..i was like oh, really..lol..good luck, keep us posted!
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  9. #24
    Registered User VRSweeney's Avatar
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    I think the upper part of the back (hump) is a popular place to gain weight in a lot of women too! My Best Friend and I are both overwieght and both have the hump....she is as regular as clock work, no PCOS or Cushings...
    Vicki (37) & Gene (36)


    Cycle #1 of Met. & Clomid : (1/08) Prov.(1500 mg Met., Clomid 50 mg) CD 2-6, (++ OPK on CD 26, tons of EWCM on CD 27)

    BFP on 2/9 10 DPO
    2/13 Beta 110; P4=51
    2/20 Beta 2416
    U/S 6w , HB 102!
    U/S 10 w, HB 160

    7/30 - It's a BOY!(Daniel)

    10/21/08 : Danny arrived! 9 lbs. 15.6 ozs.

  10. #25
    Registered User britni's Avatar
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    i was tested for it 1 yr ago. the test came back neg. which was a big weight off my back. one less problem considering i also have issues with my heart and celiac disease.

  11. #26
    Registered User PCOSBill's Avatar
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    Well, just dropped off my 24 hour tour of duty at the doctor's office.

    Here's the thing that disturbs me initially: They gave me a 3 liter jug. I filled it. Well, okay, not overflowing, but it was to the point that if I peed one more time, it would have made it to the overflowing point.

    I didn't drink excessively yesterday, and I didn't drink anything with a diuretic sort of effect.... Recently (like over the last three or four months) I've noticed I've been peeing a lot, esp. before killer headaches (of which I get a few a week). I just didn't realize, that every time I pee, I am peeing out 6-12 oz of urine!

    Does PCOS generally do that to people? I know Cushing's can, but even though I have a lot of Cushings symptoms (I don't really look Cushings... no hump, anyway) I really don't think I have it...

    Gah. The wait for these results (and the next sets) might be horrendous. Anyone know how long it takes to get the results?

  12. #27
    Sleepy Cyster novachick's Avatar
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    PCOS, have you been tested for diabetes yet as part of your PCOS diagnosis? 'Cause crazy peeing is one of the primary diagnostic signs (although it usually goes along with crazy thirst, which you didn't mention).

    Hmm!
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    dx: PCOS - July 2007, IR/Pre-diabetic - September 2007, IBS/Hiatal Hernia - June 2008, GERD/Barrett's Esophagus - July 2008
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  13. #28
    Registered User PCOSBill's Avatar
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    Been tested for diabetes... I have some crazy impaired glucose tolerance, but it's not officially diabetes. (My fasting numbers are good, usually, and two hours after eating my numbers are normal. However, they can crash... seemingly at random... down to the 55-60 range....) I try to stay away from things that make me crash (for instance, non-sugary cereal is okay to eat, but if I mix milk with it! BOOM!)

    I don't really get overly thirsty. It's very strange. I noticed most of the "pee action" goes on in the morning.... I think I went about six times in the first four hours I was awake. Then it slowed in the afternoon, picked up around dinner for an hour or so, and slowed again at night. I don't generally ever wake up having to pee. It's very rare.

    But I can wake up, pee, and I swear some mornings it's literally every 15-30 minutes I'm going... Those are usually the days I get the real good migraines. I always thought, though, when I peed only a little was coming out... But I was peeing sometimes the equivalent of a Big Gulp! (sorry to be gross. )

    I noticed the pee/migraine connection about two years ago, but it's only been over the last few months I've been peeing to the point that it's like... My god, I've got to go AGAIN?!

    PCOSBill

  14. #29
    Registered User jmgibbs's Avatar
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    PCOSBill-Could the migraines be from dehydration since you are peeing so much? Just a thought!

    I too did the 24 hour urine test for Cushings, it was neg. But I have had a tumor on my pituitary in the past so this next appt with the endo, I will push for an MRI.
    Jayna (34)/DH (34)
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    DD Alayna 11.11.08

    The trick for us was 2000 mg Metformin, 500mg of Vitex, Chiropractor, and lots of prayer.
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  15. #30
    Registered User PCOSBill's Avatar
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    Interesting thought... I dunno. I don't always need to pee a lot when I get migraines, and vice versa.... But I've noticed that there is an increase of the two occuring together.

    I got impatient, called yesterday to see when the pee results would be in... They said not till Thursday. Gah!

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