What We Know Just Changed: "Adrenal glands produce ACTH"

NOTE:  I wrote this blog entry after taking my sleeping pill for the night. I'll reread this in a few days and catch any errors. Right now, my eyes are blurry and my hands don't want to touch the correct keys. :)

What we know about Cushing's has just changed. I mean, for me, it has changed in a profound way, just in the reading of one press release online tonight.

I have seen many Cushing's patients go through one, two, or more pituitary surgeries once hypercortisolemia is detected.   Once doctors sheepishly diagnose patients with Cushing's, they shepherd us into pituitary surgery.  WHY?  

• The medical literature indicates that 70% of Cushing's cases are due to a pituitary tumor;
• Nodules rarely appear on the patient's CT scans of the adrenals that would suggest an adrenal source of Cushing's (syndrome);  
• These patients can have high ACTH (indicating pituitary source) or normal ACTH, so the likely surgical target is the pituitary;
• We patients seek a cure from this physical, emotional, and mental H- E- double hockey sticks, and we follow our doctors' advice;
  
• It's all we know about Cushing's at this time in history.

Despite all that, unfortunately, patients are often uncured by pituitary surgeries and choose the last resort treatment of bilateral adrenalectomy (BLA) to stop high cortisol at its source and gamble for an improved quality of life.  My minds often drifts back to an informal online survey of Cushing's patients who underwent BLA as treatment indicate that their adrenal glands were "plump" and "dense when removed."  Surgeons note this upon removing the adrenal glands and often include this information into the surgical reports, and pathology reports show that Cushie adrenals often weigh much more than the normal four to six grams each with fat dessicated. It is not uncommon for a patient's adrenal glands to weigh 10 and 15 grams each.  How? Why?  For those I've spoke with online, we don't know the answer.  I personally haven't seen anything written about the size of adrenal glands in relation to high cortisol and Cushing's. These dense behemoth little trouble makers trick us, because they don't appear larger on the CT scans. Radiologist love to say "adrenal glands normal in size" or they run them together with no special mention, such as "kidneys, adrenals, liver, and pancreas appear normal in size".  The surgeon sees the size of the adrenals first, kinda like finding out the gender and weight of new babies, except our surgeon removes adrenal twins, both weighing more than their mamas and papas could safely carry, so they had to come out. The size of the babies are often a surprise to everyone!

Oh, yeah. Back to the press release that says "Adrenal glands produce ACTH."

Today after our Thanksgiving dinner and celebration, I happily turned to my new iPhone 5s, another thing for which I am extremely grateful (as well as communicating with people from my bed while resting).  I stopped in my tracks when I read this press release from the New England Journal of Medicine regarding a genetic link to bilateral adrenal Cushing's.  I couldn't believe my eyes.  

A test? A genetic link?  So this would tell if we patients indeed had Cushing's, which endocrinologists are always insisting we don't really have, and they can screen our family members to get them the care they need more urgently?  WOW. This is good.

It was the first time I had ever seen the words "bilateral adrenal Cushing's."  I have seen Cushing's disease, typically referring to a pituitary source of high cortisol, and Cushing's syndrome, which refers to an adrenal source. What is this "bilateral adrenal Cushing's", asks the person about to undergo a bilateral adrenalectomy?

WHOA. Does this new article due out on Black Friday 2013 really say what I think it says in the press release?  

"The adrenal glands from the same type of patients with two large adrenal glands can produce ACTH, which is normally produced by the pituitary gland." [blogger emphasis] 

Without reading the whole article, this sure sounds to me like these researchers in France might have determined that the adrenal glands produce ACTH, not just cortisol.  I wonder if the production mechanism is similar to an ectopic location such as the lungs or ovary? I can't tell what it means from the press release, which I have pasted below.  We may have to wait until Friday, after Thanksgiving, to see if the NEJM folks are really working or shopping.  

POST THAT ARTICLE!  This way more important than any deal on a waffle iron, a Monsters University DVD, or boots with fuzzy crap on the outside.

We, the Cushing's community, are waiting for the full article!!

*** PRESS RELEASE BELOW ***

Are you carrying adrenal Cushing's syndrome without knowing it?

Genetic research that will be published tomorrow in the New England Journal of Medicine suggests to

Dr. André Lacroix, professor at the University of Montreal, that clinicians' understanding and treatment of a form of Cushing's syndrome affecting both adrenal glands will be fundamentally changed, and that moreover, it might be appropriate to begin screening for the genetic mutations that cause this form of the disease.

"Screening family members of bilateral adrenal Cushing's syndrome patients with genetic mutations may identify affected silent carriers," Lacroix said in an editorial in the Journal. "The development of drugs that interrupt the defective genetic chemical link that causes the syndrome could, if confirmed to be effective in people, provide individualized specific therapies for hypercortisolism, eliminate the current practice of removing both adrenal glands, and possibly prevent disease progression in genetically affected family members."

Adrenal glands sit above the kidneys are mainly responsible for releasing cortisol, a stress hormone. Hypercortiolism means a high level of the adrenal hormone cortisol, which causes many symptoms including weight gain, high blood pressure, diabetes, osteoporosis, concentration deficit and increased cardiovascular deaths.

Cushing's syndrome can be caused by corticosteroid use (such as for asthma or arthritis), a tumor on the adrenal glands, or a pituitary gland that releases too much ACTH. The pituitary gland sits under the brain and releases various hormones that regulate our bodies' mechanisms.

Jérôme Bertherat is a researcher at Cochin Hospital in Paris. In the study he published today, he showed that 55% of Cushing's Syndrome patients with bilaterally very enlarged adrenal glands have mutations in a gene that predisposes to the development of adrenal tumours. This means that bilateral adrenal Cushing's is much more hereditary than previously thought. The new knowledge will also enable clinicians to undertake genetic screening. Hervé Lefebvre is a researcher at the University Hospital in Rouen, France. His research shows that the adrenal glands from the same type of patients with two large adrenal glands can produce ACTH, which is normally produced by the pituitary gland. Hormone receptors are the chemical link that cause a cell to behave differently when a hormone is present. Several misplaced hormone receptors cause the ACTH to be produced in the enlarged benign adrenal tissue. Knowing this means that researchers might be able to develop drugs that interrupt the receptors for these hormones and possibly even prevent the benign tissue from developing in the first place.

More information: 

André Lacroix, M.D., Heredity and Cortisol Regulation in Bilateral Macronodular Adrenal Hyperplasia, New England Journal of Medicine 369;22, November 28, 2013 

Estelle Louiset, Ph.D., Céline Duparc, Ph.D., Jacques Young, M.D., Ph.D., Sylvie Renouf, Ph.D., Milène Tetsi Nomigni, M.Sc., Isabelle Boutelet, Ph.D., Rossella Libé, M.D., Zakariae Bram, M.Sc., Lionel Groussin, M.D., Ph.D., Philippe Caron, M.D., Antoine Tabarin, M.D., Ph.D., Fabienne Grunenberger, M.D., SophieChristin-Maitre, M.D., Ph.D., Xavier Bertagna, M.D., Ph.D., Jean-Marc Kuhn, M.D., Youssef Anouar, Ph.D., Jérôme Bertherat, M.D., Ph.D., and Hervé Lefebvre, M.D., Ph.D., Intraadrenal Corticotropin in Bilateral Macronodular Adrenal Hyperplasia, New England Journal of Medicine 369;22, November 28, 2013. 

Guillaume Assié, M.D., Ph.D., Rossella Libé, M.D., Stéphanie Espiard, M.D., Marthe Rizk-Rabin, Ph.D., Anne Guimier, M.D., Windy Luscap, M.Sc., Olivia Barreau, M.D., Lucile Lefèvre, M.Sc., Mathilde Sibony, M.D., Laurence Guignat, M.D., Stéphanie Rodriguez, M.Sc., Karine. "Are you carrying adrenal Cushing's syndrome without knowing it?." PHYSorg.com. 27 Nov 2013.

http://medicalxpress.com/news/2013-11-adrenal-cushing-syndrome.html

Perlemoine, B.S., Fernande René-Corail, B.S., Franck Letourneur, Ph.D., Bilal Trabulsi, M.D., Alix Poussier, M.D., Nathalie Chabbert-Buffet, M.D., Ph.D., Françoise Borson-Chazot, M.D., Ph.D., Lionel Groussin, M.D., Ph.D., Xavier Bertagna, M.D., Constantine A. Stratakis, M.D., Ph.D., Bruno Ragazzon Ph.D., and Jérôme Bertherat, M.D., Ph.D., ARMC5 Mutations in Macronodular Adrenal Hyperplasia with Cushing's Syndrome, New England Journal of Medicine 369;22, November 28, 2013

Provided by University of Montreal

This document is subject to copyright. Apart from any fair dealing for the purpose of private study, research, no part may be reproduced without the written permission. The content is provided for information purposes only.  [The blogger provides this information for information purpose only. The blogger generates no advertising income, and all articles are presented to educate the patient, family member, or friend who may be facing Cushing's.]

My Very Own "CSI: Cyclical Cushing's"

HAS AN ENDOCRINOLOGIST EVER TOLD YOU THAT CYCLICAL CUSHING'S WAS NEW OR RARE?

For the past six years or 2,190 days, my battle with Cushing's has been a lopsided fight. As a new patient, I went in totally unarmed, with only my patient history, medical knowledge, lab protocals, medical literature, etc. We all know, facts, stories, labs, and witnesses weren't enough to corroborate this bizarre tale of strange physical deformities and an emotional roller coaster ride.  We were completely unarmed against the MDs who stood before us.  

I have spent my time in the chat room trenches with our Cushie platoon, breaking down all the information, developing hypotheses, discussing theories, and offering help. It's very difficult to move beyond that when we, the patients, have critical information about our peers yet it goes unpublished by our doctor friends in the endocrinology.
For example, many endocrinologists I know tell me that cyclical Cushing's is very rare, fairly new, and poorly defined. Cyclical Cushing's is not well understood in the medical literature. Although I respond with a "Well, we have a lot of friends on the message boards with Cyclical Cushing's, so that doesn't do much good for me," it is undoubtedly a conversation killer. My having no come back to that questionable remark about the RARITY of Cyclical Cushing's has always bothered me to the core.

Well, I've complained about that before, but TODAY what is chapping my hide is this article I found after a simple Google search for the keywords Cyclical Cushing's.
First, you will read in the abstract that more than five cases were cyclical. By the end, there are more.


Second, I was really beside myself in a FIT when I reviewed the dates for these articles in the Selected References.  I will highlight some below. You will see some medical journal articles cited from 1956 and later.  Cyclical Cushing's has been studied and written on 50 years before I sought diagnosis and treatment in 2007. Why did these endocrinologist bozos act like they didn't know anything about cyclical Cushing's? What are these teachers teaching these endocrinologists in medical school? Why did they all treat me like there was just NO POSSIBLE WAY I had cyclical Cushing's and thereby must just be depressed, fat, extra body-haired, bruised, forgetful but rageful person. I am so furious that I always pressed for more information about cyclical Cushing's, and few had a comprehensive answer explaining what we DO know about the matter.

Please take the time to read this article below, as my flabbergasted mind and I sit here wondering how these countless endiots could not remember even ONE of the 13 articles referenced in the article alone that studies fluctuating or cyclical cortisol when I questioned them about cyclical Cushing's.


Another choice bit: the referenced articles below were published in 1956, 1958, 1961, 1973, 1975, 1976 (2), 1979 (3), 1980, 1982, and 1985. Any one of these show researchers had already discovered the distinct subset of cyclical Cushing's patients and tried to determine the best way to diagnose and treat patients.  From what I have seen 30 to 55 years later to the present, it seems that garden-variety endocrinologists and even well renowned pituitary centers have been riding on the diabetes bus (obesity! heart attacks! exercise! insulin!) all the while totally neglecting data that others clearly have shown us so long before. 


Does anyone coming out of medical school know how to research and prepare a proper literature review? Do they just ignore the clankiness of old articles and focus on single-hospital data studies?  I am mean, come on, people!  Do I have to do everything?  


When I cool down, I'll begin to read the articles post below (with links). I am truly interested to figure out who knew what and when.  This is my own CSI: Cyclical Cushing's.   

******************
PMCID: PMC1418075

Five cases of cyclical Cushing's syndrome.
A B Atkinson, A L Kennedy, D J Carson, D R Hadden, J A Weaver, and B Sheridan


British Medical Journal (Clinical Research Ed) . 1985 November 23; 291(6507): 1453–1457.

Abstract

Reported cases of cyclical Cushing's syndrome are rare. Of 14 successive patients with Cushing's syndrome nine collected sequential urine samples for the estimation of cortisol:creatinine ratio. Five had cyclical Cushing's syndrome while two had considerable variation in urinary cortisol excretion without a cyclical pattern being established. Two of the five patients with a cyclical syndrome had paradoxical responses to dexamethasone. In only one patient with a cyclical pattern did the cortisol:creatinine ratio fall after treatment with bromocriptine or cyproheptadine, or both. The high incidence of the cyclical form of Cushing's syndrome has important clinical implications. A high index of suspicion of the syndrome is required in patients with symptoms or signs of Cushing's syndrome but with normal cortisol values, in patients with fluctuating cortisol values, and in patients with anomalous responses to dexamethasone. Because of possible variations in steroidogenesis the results of drug studies in Cushing's syndrome must be interpreted cautiously.

Full text

Full text is available as a scanned copy of the original print version. Get a printable copy (PDF file) of the complete article(989K), or click on a page image below to browse page by page. Links to PubMed are also available for Selected References.

Selected References
These references are in PubMed. This may not be the complete list of references from this article.

• Bailey RE. Periodic hormonogenesis--a new phenomenon. Periodicity in function of a hormone-producing tumor in man. J Clin Endocrinol Metab. 1971 Mar;32(3):317–327.[PubMed]

• Brown RD, Van Loon GR, Orth DN, Liddle GW. Cushing's disease with periodic hormonogenesis: one explanation for paradoxical response to dexamethasone. J Clin Endocrinol Metab. 1973 Mar;36(3):445–451. [PubMed]

• BIRKE G, DICZFALUSY E. Fluctuation in the excretion of adrenocortical steroids in a case of Cushing's syndrome. J Clin Endocrinol Metab. 1956 Feb;16(2):286–290. [PubMed]

• Chajek T, Romanoff H. Cushing syndrome with cyclical edema and periodic secretion of corticosteroids. Arch Intern Med. 1976 Apr;136(4):441–443. [PubMed]

• Liberman B, Wajchenberg BL, Tambascia MA, Mesquita CH. Periodic remission in Cushing's disease with paradoxical dexamethasone response: an expression of periodic hormonogenesis.J Clin Endocrinol Metab. 1976 Oct;43(4):913–918. [PubMed]

• Oates TW, McCourt JP, Friedman WA, Agee OF, Rhoton AL, Thomas WC., Jr Cushing's disease with cyclic hormonogenesis and diabetes insipidus. Neurosurgery. 1979 Nov;5(5):598–603. [PubMed]

• Cook DM, Kendall JW, Jordan R. Cushing syndrome: current concepts of diagnosis and therapy. West J Med. 1980 Feb;132(2):111–122. [PMC free article] [PubMed]

• Schteingart DE, McKenzie AK. Twelve-hour cycles of adrenocorticotropin and cortisol secretion in Cushing's disease. J Clin Endocrinol Metab. 1980 Nov;51(5):1195–1198.[PubMed]

• Jordan RM, Ramos-Gabatin A, Kendall JW, Gaudette D, Walls RC. Dynamics of adrenocorticotropin (ACTH) secretion in cyclic Cushing's syndrome: evidence for more than one abnormal ACTH biorhythm. J Clin Endocrinol Metab. 1982 Sep;55(3):531–537. [PubMed]

• Crapo L. Cushing's syndrome: a review of diagnostic tests. Metabolism. 1979 Sep;28(9):955–977. [PubMed]

• Riad-Fahmy D, Read GF, Gaskell SJ, Dyas J, Hindawi R. A simple, direct radioimmunoassay for plasma cortisol, featuring a 125I radioligand and a solid-phase separation technique. Clin Chem. 1979 May;25(5):665–668. [PubMed]

• Cook JG. Factors influencing the assay of creatinine. Ann Clin Biochem. 1975 Nov;12(6):219–232. [PubMed]

• Atkinson AB, Chestnutt A, Crothers E, Woods R, Weaver JA, Kennedy L, Sheridan B. Cyclical Cushing's disease: two distinct rhythms in a patient with a basophil adenoma. J Clin Endocrinol Metab. 1985 Feb;60(2):328–332. [PubMed]

• Scott RS, Espiner EA, Donald RA. Intermittent Cushing's disease with spontaneous remission.Clin Endocrinol (Oxf) 1979 Nov;11(5):561–566. [PubMed]

• PASQUALINI RQ, GUREVICH N. Spontaneous remission in a case of Cushing's syndrome. J Clin Endocrinol Metab. 1956 Mar;16(3):406–411. [PubMed]

• BASSOE HH, EMBERLAND R, STOA KF. Fluctuating steroid excretion in Cushing's syndrome. Acta Endocrinol (Copenh) 1958 Jun;28(2):163–168. [PubMed]

• Aber CP, Cheetham HD. Cyclical Cushing's Syndrome. Br Med J. 1961 Feb 4;1(5222):336–338.[PMC free article] [PubMed]

• Blau N, Miller WE, Miller ER, Jr, Cervi-Skinner SJ. Spontaneous remission of Cushing's syndrome in a patient with an adrenal adenoma. J Clin Endocrinol Metab. 1975 Apr;40(4):659–663. [PubMed]

• Green JR, van't Hoff W. Cushing's syndrome with fluctuation due to adrenal adenoma. J Clin Endocrinol Metab. 1975 Aug;41(2):235–240. [PubMed]

• Bochner F, Burke CJ, Lloyd HM, Nurnberg BI. Intermittent Cushing's disease. Am J Med.1979 Sep;67(3):507–510. [PubMed]

Nocturnal Salivary Cortisol May Prove to be an Additional Option or Replacement for Early Morning Urine in Detecting Cyclical Cushing's Syndrome

Ireland, well done you!  Doctors continue to confirm the legitimacy of nighttime cortisol saliva samples in diagnosing Cushies. By now, this should totally be a given, but I am always please to see it repeated. Also, I find it interesting that the Irish use early morning cortisol-to-creatinine urine samples to diagnose. Hmm. Don't think I've heard of that being used in the USA. Nice to see the give the patient the opportunity to show high cortisol results in 28 days, not a few point-in-time tests that don't "catch" the high cortisol.  

*********

A comparison of the use of urinary cortisol to creatinine ratios and nocturnal salivary cortisol in the evaluation of cyclicity in patients with Cushing's syndrome.

J Clin Endocrinol Metab. 2013 Jan; 98(1):E72-6. doi: 10.1210/jc.2012-2925. Epub 2012 Nov 12.  

Graham UM, Hunter SJ, McDonnell M, Mullan KR, Atkinson AB. 

http://www.ncbi.nlm.nih.gov/pubmed/23150688

Source

Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BA, United Kingdom. qublbc8@hotmail.com

Abstract

CONTEXT:

Cyclical Cushing's syndrome is detected in our center by collecting sequential early morning urine (EMU) samples for cortisol to creatinine ratio over 28 d. The Endocrine Society suggests that nocturnal salivary cortisol (NSC) may be used to assess patients for cyclical Cushing's. However, there is only very limited evidence that it correlates with early morning urine testing or that it demonstrates cycling over 28 d.

OBJECTIVE:

We sought to correlate nocturnal salivary cortisol with early morning urine results collected the following morning and to determine whether nocturnal salivary cortisol could be used to detect cyclical Cushing's.

DESIGN AND SETTING:

An observation study of 28-d collections for nocturnal salivary cortisol and early morning urine was performed in a tertiary referral center over 1 yr. Patients: A 28-d collection of nocturnal salivary cortisol and early morning urine was performed in 10 patients with confirmed or suspected Cushing's syndrome.

MAIN OUTCOME MEASURE:

The main outcome of the study was the correlation of salivary and urinary cortisol with graphical assessment of results for cycling.

RESULTS:

Eleven collections were performed. One patient with cyclical Cushing's completed the collection before and after cabergoline therapy. Two hundred seventy matched salivary and urinary results were correlated (r = 0.79; P < 0.001). In two patients with cyclical Cushing's, early morning urine and nocturnal salivary cortisol followed a similar cyclical pattern. In one patient with recurrent cyclical Cushing's, cortisol was elevated in both saliva and urine but with more prominent cycles in saliva.

CONCLUSION:

Nocturnal salivary cortisol correlated well with early morning urine. Nocturnal salivary cortisol detected all cases of cyclical Cushing's. Therefore, nocturnal salivary cortisol may prove to be an additional option or replacement for early morning urine in detecting cyclical Cushing's syndrome. [blogger emphasis]

PMID:  23150688 [PubMed - indexed for MEDLINE]

NOTE: Blogger changed all abbreviations for EMU and NSC to early morning urine and nocturnal salivary cortisol. This Cushie brain can’t remember what these mean half way down the article.

Europe Continues to Lead Research on Cyclical Cushing's

It is my strong belief that European endocrinologists and research will pave the way for cyclical patients in the United States, who continue to struggle.

Don't believe me?

Well, I point you to many articles that consistently come out of Ireland, Italy, Germany, France, England, Serbia, Spain, and others I can't remember now. When I get a chance, I'll try to post a link with all of these articles in one place. Until then, please, I beg you. Trust me on this.

I have read many articles on cyclical Cushing's -- after searching high and low for them. These articles come primarily from our European friends. 

Common knowledge about cyclical Cushing's must be racing around the continent on those bullet trains (which I adore, by the way!).

A Comparison of the Use of Urinary Cortisol to Creatinine Ratios and Nocturnal Salivary Cortisol in the Evaluation of Cyclicity in Patients with Cushing's Syndrome Authors 1.    U. M. Graham, 2.    S. J. Hunter, 3.    M. McDonnell, 4.    K. R. Mullan and 5.    A. B. Atkinson 1.   Regional Centre for Endocrinology and Diabetes (U.M.G., S.J.H., K.R.M., A.B.A.) and Regional Endocrine Laboratory (M.McD.), Royal Victoria Hospital, Belfast BT12 6BA, United Kingdom 1.    Address all correspondence and requests for reprints to: Dr. Una Graham, Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BA, United Kingdom. E-mail: qublbc8@hotmail.com. Abstract Context: Cyclical Cushing's syndrome is detected in our center by collecting sequential early morning urine (EMU)* samples for cortisol to creatinine ratio over 28 d. The Endocrine Society suggests that nocturnal salivary cortisol (NSC)* may be used to assess patients for cyclical Cushing's. However, there is only very limited evidence that it correlates with early morning urine testing or that it demonstrates cycling over 28 d. Objective: We sought to correlate nocturnal salivary cortisol with early morning urine results collected the following morning and to determine whether nocturnal salivary cortisol could be used to detect cyclical Cushing's. Design and Setting: An observation study of 28-d collections for nocturnal salivary cortisol and early morning urine was performed in a tertiary referral center over 1 yr. Patients: A 28-d collection of nocturnal salivary cortisol and early morning urine was performed in 10 patients with confirmed or suspected Cushing's syndrome. Main Outcome Measure: The main outcome of the study was the correlation of salivary and urinary cortisol with graphical assessment of results for cycling. Results: Eleven collections were performed. One patient with cyclical Cushing's completed the collection before and after cabergoline therapy. Two hundred seventy matched salivary and urinary results were correlated (r = 0.79; P < 0.001). In two patients with cyclical Cushing's, early morning urine and nocturnal salivary cortisol followed a similar cyclical pattern. In one patient with recurrent cyclical Cushing's, cortisol was elevated in both saliva and urine but with more prominent cycles in saliva. Conclusion: Nocturnal salivary cortisol correlated well with early morning urine (EMU). Nocturnal salivary cortisol detected all cases of cyclical Cushing's. Therefore, nocturnal salivary cortisol may prove to be an additional option or replacement for early morning urine in detecting cyclical Cushing's syndrome.

* For ease of reading, blogger changed all EMU to early morning urines and all NSC to nocturnal salivary cortisol. A Cushie brain is far too foggy to keep even these simple conventions straight even when reading a brief article. 

BlogTalkRadio with Dr. Friedman

Struggling with Cushing's?

Undiagnosed but your gut says you have it?

Post op pituitary surgery?

Persistent Cushing's and still sick?

Pre-op or post-op bilateral adrenalectomy? 

This series of free online radio chats are for you.

MaryO, founder of Cushings-Help.com and Cushie.info, and Robin, active board member/blogger of Survive the Journey and Cushing's 365, interview Dr. Theodore Friedman, an endocrinologist based in Los Angeles, CA.  Dr Friedman has helped many fellow Cushies, and I am proud to have him as my doctor now.

- CushingsHelp | Internet Radio | Blog Talk Radio -

Interview with Dr. Ted Friedman DR. F 1/29/2009

Second Interview with Dr. Ted Friedman DR. F 3/12/2009

Dr. Ted Friedman Returns for his Third Interview 2/13/2011

In his private practice, Dr Friedman charges $450 an hour for his time. He has generously donated three hours to us Cushies in these blog chats, and it is far more valuable than the $1,350 you would have paid if you had the exact same conversations in his office. This information is priceless, because it *empowers* patients with knowledge to overcome this rare and rascally disease that doesn't want to go down without a fight.

These chats explain why our local endocrinologists' conventional understanding of and protocol for cushing's does not help all of us. In fact, Dr. Friedman helps us understand that the process of testing, diagnosis, treatment, and surgery (-ies) for patients with cyclical cushing's is very different from florid Cushing's patients.  He and his colleagues work very hard to ensure his research findings make their way into the medical literature in hopes of shaping future treatment of mild or episodic Cushing's patients. Also, be sure to read Dr Friedman's latest paper, aptly titled:

High Prevalence of Normal Tests Assessing Hypercortisolism in Subjects with Mild and Episodic Cushing’s Syndrome Suggests that the Paradigm for Diagnosis and Exclusion of Cushing’s Syndrome Requires Multiple Testing