Cushing's

Hypercortisolism occurs when your body makes too much cortisol. Left untreated, it can cause changes to your physical appearance, such as:

• Moon face
• A hump on the back of your neck
• Rapid weight gain, mostly around the stomach
• Purple stretch marks, especially around the torso
• Excessive bruising
• Facial hair or acne

Cushing’s Syndrome vs Cushing’s Disease 
Cushing’s syndrome is a general term that means your body has been exposed to chronically high cortisol levels due to a variety of factors that could include taking steroids or adrenal gland tumors.

Cushing’s disease occurs when elevated cortisol levels are caused by a pituitary gland tumor that secretes adrenocorticotropic hormone (ACTH), which stimulates cortisol production from the adrenal glands. Both conditions are rare, but require a prompt diagnosis and effective treatment to help prevent complications. 

If left untreated, complications of Cushing's can include:

• Diabetes
• Hypertension
• Osteoporosis
• Increased risk of blood clots

Late Night Saliva Cortisol Collection 
Spit is collected before bedtime to identify high cortisol levels. Cortisol levels are usually lowest before going to sleep.

24-Hour Urine-Free Cortisol
Your urine is collected over 24 hours, then analyzed to determine how much cortisol your body produces.

Dexamethasone Suppression Test
A steroid called dexamethasone is taken at 11:00 pm. At 8:00 am the following day, your blood will be drawn to measure cortisol levels.

Imaging
Imaging scans help determine the cause of your hypercortisolism. An MRI will take images of your pituitary gland. An abdominal CT scan will look for tumors in your adrenal glands.

Bilateral inferior petrosal sinus sampling 
If imaging is inconclusive, your doctor may perform a bilateral inferior petrosal sinus sampling. During this minimally invasive procedure, blood samples are drawn from your inferior petrosal sinuses, which are close to your pituitary gland. The results are compared to blood samples taken from your arm. If ACTH hormone (a hormone that stimulates cortisol production) levels closer to the pituitary gland are above a certain ratio compared to the peripheral level, this could indicate that your pituitary gland is the cause.

Transsphenoidal Surgery
If a pituitary tumor is the cause of your hypercortisolism, surgery to remove it is often the first treatment. Your surgeon inserts a tube through your nasal passages and the sphenoid sinus to access the pituitary gland at the bottom of your brain. They will remove all or as much of the tumor as possible. Even if the entire tumor has been removed, Cushing’s disease can recur, so you will need regular monitoring.

Medical Treatment

• Adrenal steroidogenesis inhibitors can help reduce or suppress the production of cortisol.
• Pasireotide works directly on the tumor by decreasing ACTH secretion.
• Mifepristone blocks cortisol action.

Radiation Therapy
If you continue to have high cortisol despite surgery and medical treatment, radiation may be an option.

Pituitary Center of Excellence
Duke Health experts are leaders in advanced treatment for people with all types of pituitary disorders. Collectively, our pituitary disorder clinics in Durham are designated a Pituitary Center of Excellence by the Pituitary Network Association, an international non-profit organization created to help people with pituitary tumors and disease.

Collaborative Approach to Care
For your convenience, we offer a special pituitary clinic that allows you to see an endocrinologist, neurosurgeon, and ophthalmologist all in one day and in one location. These experts meet with you to review your case, order the appropriate tests, and offer recommendation for next steps.

Minimally Invasive Procedures
Minimally invasive procedures require smaller incisions than open surgery, which means you experience less pain, faster recovery, and fewer complications. Our highly specialized surgeries include transsphenoidal resection for pituitary disorders and tumors.