Cushing's Disease - Pituitary Foundation

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What is Cushing’s?

The condition is named after Harvey Cushing, an eminent American neurosurgeon who described the first patients with this condition in 1912.

Cushing’s syndrome develops if your body makes too much of a hormone called cortisol.

Cortisol is made by the adrenal glands (two small glands which lie just above each kidney) and it is vital for life. It has several functions including:

Helping to regulate blood pressure
Helping to regulate the immune system
Helping to balance the effect of insulin to keep blood sugar normal
Helping the body to respond to stress

Why do we get Cushing’s?

The most common reason that people develop Cushing’s is glucocorticoid treatment – for example, taking a steroid such as prednisolone for asthma, arthritis or colitis. This type of Cushing’s is known as exogenous Cushing’s.

Another type of Cushing’s, known as spontaneous Cushing’s, occurs when the condition originates from within the body (e.g. is not due to taking medication). This is rare but occurs when the adrenal glands are making too much cortisol (the body’s natural glucocorticoid steroid hormone).

Spontaneous Cushing’s may happen for one of several reasons, so you will have tests to find out which reason applies to you. The quoted incidence of Cushing’s is 1 in 200,000 but it is now being found more frequently when it is specifically investigated. The symptoms of Cushing’s can be very wide ranging and thus the diagnosis may not necessarily be considered. It can also be difficult to establish at the earlier stages and this can cause a delay in diagnosis.

Far more women than men experience Cushing’s but it is not known why. It is most commonly diagnosed between the ages of 30 to 40. Although it is rare in children, some as young as six have been diagnosed. There are no environmental triggers known and it’s not hereditary.

Causes

A pituitary gland tumour

The most common cause of spontaneous Cushing’s (accounts for around 70% of cases) is a small benign (non-cancerous) tumour of the pituitary gland. This tumour causes the pituitary gland to produce too much of a hormone called ACTH, (adrenocorticotrophic hormone), which goes through the blood stream to the adrenal glands and causes them to release too much cortisol. In this case there is a good chance that an operation on your pituitary gland, to remove the tumour, will solve the problem.

A tumour elsewhere in the body

Sometimes, the tumour that is causing Cushing’s is not found in the pituitary gland. There could be a small growth in another part of your body that is producing ACTH (this is called ectopic ACTH), leading to overproduction of cortisol. If so, removing this growth will usually solve the problem.

Tumour of the adrenal glands

The adrenal glands are small, hormone-secreting glands that sit above each kidney. A small growth in one of the adrenal glands can cause Cushing’s. In this case, an operation will be needed to remove that gland. In some circumstances it may be necessary to remove both adrenal glands to solve the problem.

Cushing’s syndrome vs Cushing’s disease

Cushing’s syndrome is the name given to any cause of high cortisol. This could be because of many different reasons, such as those listed above. If Cushing’s is caused by a growth in the pituitary gland then the correct name is Cushing’s disease.

Cyclical Syndrome

Sometimes, the amount of cortisol causing the condition can vary greatly. This is called ‘Cyclical Cushing’s’ with varying symptoms, often over months or even years depending on the levels of cortisol. This can cause difficulty and delays in diagnosis. Occasionally, repeated testing by your endocrinologist will be needed to assess whether you have this more uncommon type of Cushing’s.

Cortisol and Cushing’s

The video below explores what cortisol is and how overproduction of this hormone leads to the symptoms seen in Cushing’s.

Symptoms of Cushing’s Disease

Cushing’s disease is a condition caused by having too much of a hormone called cortisol in your body. There are a wide range of varied symptoms for Cushing’s Disease, and usually several are present at once.

What are the symptoms of Cushing’s disease?

The symptoms of Cushing’s disease are varied and usually develop gradually, so a diagnosis may not be clear for some time. Usually several symptoms are present at once.

Symptoms include:

Excessive and sudden (or at times more gradual) onset of weight gain around your trunk; your arms and legs may remain unchanged and can become quite thin compared to your body)
Fatty hump at top of spine/back (also known as an interscapular hump)
Weak muscles, especially in your legs
Your face tends to be rounder and redder than normal (a classic symptom of Cushing’s known as ‘moon face’) and you may have developed acne
Darkening of skin pigmentation
Your bones may have become weaker (an X-ray may show a fractured rib for instance), due to steroid-induced osteoporosis (thinning and brittleness of bones) and therefore you have an increased risk of fracture
Your blood pressure may be higher than normal (hypertension) and you could have developed diabetes mellitus (‘sugar diabetes’) and excess thirst
Some people may also notice a tendency to bruise easily and have deep red/purple stretch marks (striae) appearing on the abdomen, similar to those which occur during pregnancy but are more pronounced. Skin can become thin and fragile.
Some people may experience irregular periods or stop having them altogether
You may also experience excessive hair growth on parts of the body and usually the face in women. Men can experience decreased fertility and both men and women can feel a reduction, or absence of sex drive (libido)
You may be feeling generally unwell, and more susceptible to infections
Mood swings – such as being more irritable, feeling depressed or anxious. In some cases, psychological problems can be severe, even being diagnosed as a nervous breakdown
In children it may show itself by growth stopping and weight increasing

Cushing’s affects many parts of the body, both mentally and physically, and affects different people in different ways.

Because Cushing’s can progress slowly and gradually, it can go unrecognised for quite some time. Looking back, many patients realise that there were clues to the condition two or more years before they were referred to an endocrinologist. However, lack of Cushing’s knowledge at the time meant they were unaware of the condition.

The video below highlights some of the common features that people with Cushing’s may experience.

Diagnosis of Cushing’s Disease

Cushing’s disease is a condition caused by having too much of a hormone called cortisol in your body. Due to the range of symptoms that occur over a long time period it can be difficult to diagnose Cushing’s.

How is Cushing’s diagnosed?

The tests used to diagnose Cushing’s are complicated and may take some time; they may also need to be repeated on several occasions. You may have them as an inpatient or an outpatient.

The first tests are to establish that Cushing’s is present. Only if the presence of Cushing’s is established are further tests performed to identify the location of the cause. This is because most people who have the symptoms of weight gain, high blood pressure, diabetes or problems with excess hair do not have Cushing’s, and so establishing is Cushing’s is present is the essential first step.

Tests to check for Cushing’s

To see if you have Cushing’s you will probably be given a tablet called dexamethasone. In people who do not have Cushing’s, taking this tablet will suppress the production of the hormone cortisol.

You may also have a series of blood tests, urine tests and late-night saliva tests. The urine test involves collecting all the urine you pass during 24 hours (for example, between nine o’clock one morning and nine o’clock the next morning). The hospital will provide a special container for this and you will be told how to take accurate and clean samples; tubes for any saliva tests will also be provided.

Locating Cushing’s

If these initial tests indicate that Cushing’s is likely, you will then need further tests to find its location. You may be admitted to hospital for these, and it is likely that you may be referred to a hospital where they are very familiar with Cushing’s.

Tests include:

blood samples taken throughout the day
a higher dose of dexamethasone
an injection of corticotrophin releasing hormone (CRH) or desmopressin (DDAVP) which stimulate the pituitary to release ACTH
measuring ACTH the blood coming from the pituitary gland – inferior petrosal sinus sampling

After the diagnostic tests have been completed your doctor may decide to treat you in the meantime with drugs, such as metyrapone or ketoconazole, to reduce the amount of cortisol produced by your adrenal glands. If so, you may have to spend two or three days in hospital to assess your response to the tablets or attend regularly as an outpatient.

At the end of all these blood tests your arms might be quite bruised, a tendency to bruise easily is typical of Cushing’s.

Scans

You will also have your pituitary and/ or body and adrenal glands scanned, using a type of magnetic scan called an MRI scan, or by a form of X-Ray called a CT scan. You may be given an injection during the scan to improve the results. A minority of patients are allergic to this injection, so do tell the specialist if you have asthma or any allergies. The scan does not hurt but the MRI machine can be noisy and it may involve being inside the scanner for around half an hour. If you think this will make you claustrophobic or nervous, tell your GP who may give you something to help you relax.

Other tests

Another test which may be carried out initially, or possibly during the follow-up to treatment, is a bone mineral density test. This will establish whether you have lost bone density and might be at risk of developing osteoporosis (thinning and brittleness of the bones).

Treatment for Cushing’s

Cushing’s disease is a condition caused by having too much of a hormone called cortisol in your body. It is often treated through an operation.

How is Cushing’s treated?

Treatment for Cushing’s disease often includes an operation and drugs may be used to reduce the amount of cortisol produced.

Surgery

If your Cushing’s is caused by a pituitary tumour (Cushing’s disease), you will usually need an operation. It is carried out under a general anaesthetic and usually involves and operation through the nose with no external scars. This is called transsphenoidal surgery. By going behind the nose in this way, the surgeon can see your pituitary gland without having to operate on the main part of your head. Sometimes the area behind the nose needs patching with tissue taken from under the skin of the thigh or abdomen during the operation which will leave a small scar there. Please see our Surgery & Radiotherapy booklet.

Most people are up and about and eating normally the following day and are back at home within a few days. Recovery times can vary. Depending on your particular job and circumstances, you should plan to be away from work for four to six weeks, maybe longer. You will need to avoid blowing your nose for three weeks or more while it heals and your front teeth may feel a bit numb for a while, occasionally permanently. You may also lose your sense of smell for weeks or months – although this usually returns to normal as the nerves re-grow.

For a few days after the operation some patients feel very thirsty and need to pass urine more than normal. This condition, called Arginine Vasopressin Deficiency (previously Diabetes Insipidus), is usually temporary but occasionally can become permanent. It can be treated by using a drug called desmopressin. Please see our leaflet called Diabetes Insipidus. You may also notice peeling of the skin as the cortisol levels fall (this is a good sign). Occasionally it is necessary to carry out a second operation if the first is not completely successful. This can sometimes be done within seven to ten days.

You will need further hormone tests, either immediately and/or four to six weeks after the operation. Again, these are usually done as an outpatient not requiring a hospital stay. These tests are designed to show whether or not the operation has been a success, and whether you have developed deficiencies of other pituitary hormones, known as hypopituitarism, which may need replacement tablets. Please see our booklet called The Pituitary Gland.

After successful surgery you are likely to feel worse for several weeks and months before you begin to feel better. Eventually, however, your strength and mood will improve over time and the other symptoms will gradually diminish. This usually takes several months, but be patient – it will happen.

Medication

You may have to take replacement cortisol (which is called ‘hydrocortisone’ when it is in tablet form) or another steroid tablet such as prednisolone, for some time after your operation to compensate for a temporary reduction in your body’s ACTH production. This occurs because the normal control mechanisms are ‘switched off’ after being exposed to too much cortisol for so long. Hydrocortisone is taken in the form of tablets, usually two or three times a day. If prescribed and you don’t take the tablets (or when they are deliberately not given immediately after the operation or during reassessment tests) you will probably feel generally weak, tired and ‘ill’. However, you will feel better after you begin to take the tablets again.

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