Dr John Bevan
Aberdeen Royal Infirmary

At Dr Bevan's workshop, we learnt that there are several forms of Cushing's, the commonest being caused by a Benign tumour of the Pituitary gland causing an overproduction of ACTH, leading to an overproduction of Cortisol. Other forms result from a tumour on the adrenal gland (usually benign) or may be ectopic, i.e. a tumour elsewhere in the body, which has learnt how to produce ACTH.

Without a precise diagnosis and treatment, Cushing's can be dangerous because it can result in high blood pressure, sugar diabetes, obesity, a poor resistance to injury and infection and an increase in spontaneous bone fractures. The good news is that in general it is curable, especially in younger patients. In older patients the condition can be stablised. This improvement may take several years and there may be a need for continuing medication.

We then explored the different signs and symptoms a patient with Cushing's may notice. These included: an increase in weight (especially around the stomach), stretch marks, a rounding and reddening of the face, mood swings, panic and depression, muscle weakness and backache, a swelling of the feet, bruising, skin infections and acne, breathlessness, a change in body odours and a reduced sex drive. Women may also be aware of changes to their periods and increased hair growth on the face. On examination, the doctor may find evidence of high blood pressure, sugar diabetes and thinning of the bones (Osteoporosis).

To confirm a diagnosis of Cushing's, a 24 hour urine test is performed (to measure cortisol levels) and an overnight dexamethasone test. This is an artifical steroid, which is used to test whether you can switch off your pituitary gland. The dexamethasone tablet is taken at midnight and a blood sample taken at 9am. If these tests suggest you have Cushing's, you are admitted to an endocrine unit for further blood tests, urine samples and scans, as it is important to establish where the tumour is, i.e. pituitary, adrenal or elsewhere.

The types of blood test performed include levels of cortisol and ACTH, a long dexamethasone test, a metyropone test, CRH test, and pituitary blood sampling for ACTH. This is a relatively new procedure, which can be painful but which can confirm the tumour is definitely pituitary. Patients attending the workshop reported experiencing headache, earache and a feeling of pressure in the head and/or groin. Some felt it was 'worse than the operation'.

A MRI scan of the pituitary is also performed. This can be "like having your head in a hole in a wall while a machine makes a noise like a washing machine full of spanners, but it is not painful". The Adrenal glands should also be scanned. If pituitary Cushing's is confirmed, drugs such as metyrapone are given to dampen down the adrenal glands prior to surgery. An operation is performed to remove the Pituitary tumour, usually by the transsphenoidal route. This has an initial cure rate of about 80%. If your cortisol levels remain high after surgery, then your adrenal gland may be removed or you may be recommended to have pituitary Radiotherapy.

After successful pituitary surgery, you will need replacement Hydrocortisone therapy and may also require other hormone replacements. You should also receive regular monitoring by an endocrine specialist who will review your blood pressure, check hormone levels, monitor your bones and check on your general well being. Relapse rates are low.

Finally, and perhaps most importantly, what can you do to help yourself? Keep optimistic, let your friends and family help. Admit you have good and bad days and rest when your body tells you to. If you are a smoker, try to stop. Listen to your doctor, ask questions and take notes. Find out as much as possible about your condition. Try to reduce the amount of tea and coffee you drink and increase the amount of water and natural fruit juices. Try to avoid highly spiced food.

Gentle exercise is important as it increases feelings of well-being and muscle strength. Swimming is very good because it supports your weight and eases pressure on weakened muscles. Aqua aerobics are also reported by some patients to be beneficial. Walking and cycling (within your limits) are also recommended. To improve your skin, cut down on the use of heavily scented soaps and perfumes. Wash and dry your skin carefully. E45 is very good for dry skin. Oily fish is reported by some patients to be very good for clearing up acne. Wear rubber gloves for washing up and other housework.

To reduce swollen feet and ankles, try and avoid taking diuretics as these worsen the body's salt imbalance (however, never stop diuretics suddenly without consulting your doctor). Elevate your legs when resting, watching TV etc., but remember to stretch regularly. The oedema will get better when the Cushing's is cured.