Psychosocial Issues

Issues relating to Cushing's:

• Loss of energy, a decreased level of activity and fitness
• Loss of libido, infertility, low sex drive, impotence
• Lack of self-esteem/confidence (body image issues) due to altered body image/physical changes/imbalance of hormones
  
• Feelings of loss of control
• Depression**/mood swings
• restlessness, agitation
• memory affected
• sleep patterns affected
  
• "Something is wrong with me"
  
• History of being treated for other stress/mood related disorders. Doctors tend to imply to patients that they suffer from psychological disorders rather than physical disorders.

Because of the above factors:

• strain on relationships
• unmarried? divorced? - could this be an underlying reason?
  
• family/relatives - unable to cope with the change in personality/mood swings etc.
  
• snide or unkind comments from family/relatives/co-workers/friends regarding inability to lose weight/other physical changes or mood changes
• strain on employment
• unable to carry out normal duties due to depressive personality
• unable to cope with stresses

Treatment/Management issues:

• "Uncertainty is worse than reality" - therefore important for patient to learn all about the condition to reduce uncertainty and perhaps aid in alleviating depression
  
• Cortisol replacement:
  
• worries regarding the ups and downs of cortisol replacement
• financial issues: able to pay for drugs? insurance?
  
• forgetting to take medication daily?
• stress!
• Surgery:
  
• distress regarding the procedures/risks
• Managing depression*:
• moderate alcohol/caffeine intake
• have hormone levels checked
• anti-depressants?
• talk with others (cognitive behaviour therapy/mindful meditation/support group)
• adequate sleep (reduced alcohol and caffeine intake helps)
• proper diet and exercise routine - even after surgery, may take a while for body to go back to 'normal'
  
• stressful life? change it! Or change reaction to stresses

Sources:
http://www.pituitary.org.uk/content/view/69/80/
http://www.pituitary.org.uk/content/view/278/157/

Definition and Causes of Cushing's Syndrome

Cushing’s Syndrome

Definition: Cushing’s Syndrome (also known as hypercorticolism) is a hormonal disorder caused by prolonged exposure of the body’s tissues to high levels of the hormone cortisol, either produced excessively by the body or through excessive intake of cortisol or other steroid hormones.

What Causes Cushing’s Syndrome?

1. Pituitary Adenomas

- most common cause (also known as Cushing’s Disease)

- benign tumors or hyperplasia of the pituitary gland, secreting increase amounts of ACTH

- affects women five times more frequently than men, and usually as a single adenoma

2. Ectopic ACTH Syndrome

- benign or malignant tumors that arise outside the pituitary gland producing ACTH

- most common is lung tumors ( >50% of ectopic cases), usually by small cell lung cancer

- thyromas, pancreatic islet cell tumors, medullary carcinomas of the thyroid (C cells)

3. Adrenal Tumors

- more commonly Adrenal Adenomas which releases excess cortisol

- Adrenocortical carcinomas, least common cause, secrete excess levels of several adrenal cortical hormones including cortisol and adrenal androgens. Cause very high hormone levels and rapid development of symptoms

4. Intake Of Glucocorticoid Hormones

- also known as Exogenous Cushing’s Syndrome

- due to intake of glucocorticoids such as prednisone or dexamethasone for treatment purposes

- for asthma, rheumatoid arthritis, lupus, inflammatory diseases, immunosuppression after transplantation

5. Familial Cushing’s Syndrome

- very rare; due to inherited tendency to develop tumors of one or more endocrine glands

- Primary Pigmented Micronodular Adrenal Disease: children or young adults develop small cortisol-producing tumors of the adrenal glands

- Multiple Endocrine Neoplasia Type I (MEN I): due to pituitary, ectopic or adrenal tumors

References

http://endocrine.niddk.nih.gov/pubs/cushings/cushings.htm

http://www.nlm.nih.gov/medlineplus/ency/article/000410.htm

Cortisol

Cortisol / Glucocortisol
Ji Keon LOOI

Outline of presentation
This presentation will cover:
•Site of production
•Site of release
•Target organ
•Means of transport
•Action
•Feedback Loop
Of cortisol

To clear things up before we start
•Two major types of adenocorticol hormones – mineralocorticoids and glucocorticoids
•Mineralocorticoids affect the electrolytes (minerals) of the ECF Na+ and K+ in particular
•Glucocorticoids increase blood glucose concentration, effects on CHO, protein and fat metabolism

The glucocorticoids
•Cortisol
•Corticosterones
•Cortisone
•Prednisone
•Methylprednisone
•Dexamethasone

Introduction to CORTISOL
•Principal glucocorticoid, 95% of all GC activity
•Secretion stimulated by ACTH, which in turn is controlled by CRF.
–What are sites of production?
•Produced by adrenal cortex
–Which layers?
•A.k.a stress hormone
•Hydrocortisone (synthetic)

Secretion of adrenocortical hormones by the different zones of the adrenal cortex and secretion of catecholamines by the adrenal medulla. (Diagram from Guyton)

Means of transport & Action
•Cortisol (hydrophobic) travels through the body in the blood via serum globulin.
•It diffuses through the cell membrane.

•Inside the cell, cortisol binds with its protein receptor in the cytoplasm, and the hormone-receptor complex (HRC) then interacts with specific regulatory DNA sequences, called glucocorticoid response elements, to induce or repress gene transcription. (Interaction facilitated by Transcription factors)
•It increases or decreases transcription of many genes to alter synthesis of mRNA for the proteins that mediate their multiple physiologic effects.
•Thus, most of the metabolic effects of cortisol are not immediate but require 45 to 60 minutes for proteins to be synthesized, and up to several hours or days to fully develop.
•N.B.: steroid hormones, exerts its effects by first interacting with intracellular receptors in target cells.

More about the stress hormone…
•Secretion in accordance with circadian rhythm. High in the early morning, low in late evening. Changes in sleeping habits alter the cycles.
–Clinical application: - measurement of blood cortisol only meaningful when expressed in terms of the time in the cycle at which the measurements are made
•Physical/Mental stress enhances secretion of ACTH and consequently cortisol.
•Negative feedback mechanism to decrease CRF and ACTH formation

Effects of Cortisol (1)
CHO metabolism
•Stimulates gluconeogenesis
•Decreases glusoce utilisation by cells
•Elevates blood glucose concentration and “adrenal diabetes”

Protein metabolism
•Reduces cellular protein
•Increases liver and plasma protein
•Increases blood aa, diminishes transport of aa into extrahepatic cells and enhances transport into hepatic cells

Fat Metabolism
•Mobilisation of FACs
•Excess results in obesity

Effects of Cortisol (2)
•Resists stress and inflammation ( )
•Blocks inflammatory response to allergic reactions
Mechanism for regulation of glucocorticoid secretion. ACTH, adrenocorticotropic hormone; CRF, corticotropin-releasing factor.


THE DISORDERS OF CORTISOL SECRETION
Plasma Cortisol Plasma ACTH

Primary Hypercortisolism ↑ ↓
(Cushing Syndrome)

Secondary Hypercortisolism ↑ ↑
(pituitary, Cushing's disease)

Primary Hypocortisolism ↓ ↑
(Addison's disease)

Secondary Hypocortisolism ↓ ↓
(pituitary)

Thank you!!!
Sources
•Guyton, Textbook of Medical Physiology 11th Edn
•Prof. Khalid’s lecture *Components of the Endocrine System*
•http://users.rcn.com/jkimball.ma.ultranet/BiologyPages/A/Adrenals.html

Risk Factors (Cushing's Syndrome)

Overview: Cushing syndrome is a disease that occurs when your body produces too much of the hormone cortisol. It may also occur if you use take too much cortisol or other steroid hormones.

RISK FACTORS

Risk factors for Cushing syndrome are adrenal or pituitary tumors, long-term therapy with corticosteroids, and being female.

1.Cushing Syndrome caused by adrenal tumors: -caused by too much production of cortisol ( stress hormone) due to an adrenal gland tumor.

*Benign for eg. Adrenal adenomas or micronodular hypeplasia
*Malignant for eg. Adrenal carcinomas

2.Cushing Syndrome caused by corticosteroids – long term use of steroids/ drugs.
Drugs commonly used to treat conditions such as rheumatoid arthritis and asthma.

3.Cushing Syndrome caused by pituitary tumor

*pituitary gland releases too much adrenocorticotropic hormone (ATCH).
*ACTH stimulates adrenal , increasing the production and release of cortisol.

Reference:
MedLinePlus
http://www.nlm.nih.gov/medlineplus/ency/article/000410.htm

Prepared by:

SRI MURNIATI ROSLI

List of symptoms of Cushing's syndrome

The list of signs and symptoms mentioned in various sources for Cushing's syndrome includes the 81 symptoms listed below:


Specific childhood or adolescent Cushing's symptoms:

Extreme weight gain
Growth retardation
Missed periods - in teenage girls
Excess hair growth
Body hair growth
Facial hair growth
Acne
Reddish-blue streaks on the skin
High blood pressure
Tiredness
Muscle weakness
Very early puberty
Very late puberty





Adult Cushing's symptoms

Extreme weight gain
Upper body obesity
Rounded face
Increased neck fat
Excess hair growth
High blood pressure
Sleep disturbances
High blood sugar
Diabetes-like symptoms
Hyperadrenocorticism
Bruising easily
Skin problems
Thin skin
Fragile skin
Poor healing
Stretch marks
Abdominal stretch marks
Mood changes
Irritability
Anxiety
Depression
Moodiness
Fatigue
Mental disturbances
Weak muscles
Backaches
Thinning arms
Thinning legs
Weak bones
Rib fractures
Spinal column fractures
Sexual and fertility problems
Irregular menstrual periods
Absent menstrual periods
Reduced libido
Reduced male fertility
Virilisation
Deepening voice
Balding
Loss of scalp hair
Hirsutism
Increased facial hair
Increased body hair
Increased weight
Rounded face
Obesity around trunk
Slender limbs
Red face
Thin skin
Fragile skin
Slow-healing skin
Weakened connective tissue
Reddish-blue stretch marks
Excessive hair thickness in women
Menstrual disorders
Impaired male fertility
Reduced male sex drive
Absent male sex drive
Hypertension
Brittle bones
Fractures
Osteoporosis
Hyperglycemia
Severe weakness
Fatigue
Psychiatric disturbances

Note that Cushing's syndrome symptoms usually refers to various symptoms known to a patient, but the phrase Cushing's syndrome signs may refer to those signs only noticable by a doctor.

By Chris
source: http://www.wrongdiagnosis.com/c/cushings_syndrome/symptoms.htm

Labelling our posts

To avoid confusion to differentiate between pcl materials from MED2031 and MED2042 since we start with Week 1 again this semester, I would suggest that we label our work according to the title of the week.

I have entered all the pcl titles under this post and they should appear when you type in the first letter into the label slot. Alternatively, click on Show all to display all the pcl title.

Thanks.

Ji Keon

Tasks for Week 1

Definition of Cushing Syndrome+Causes - Vivian
Signs & Symptoms - Chris
Risk Factors - Sri
Pathophysiology- Christine
Overview of Cortisol Pathway & Effects - Looi
Investigations+Differentials (Compare with Obesity & Menopause) - John
Management & Prognosis - Lawrence
Alternative Treatment (Green Tea etc.) - Shantz
Psychosocial Issues - Maddie :P

All the best for the exam....

chris