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Suggest treatment for high Cortisol levels in body, hypothyroidism and PCOS during pregnancy

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Posted on Mon, 30 Nov 2015
Question: I have hypothyroidism and polycystic ovaries . by august 2012 until now I've taken 15kgs and keep taking . i use t4 150mg , glucophage 850mg and XXXXXXX i think i may have cushing syndrome. my cortisol level in blood is 34 in the morning but in 24hr in urine is in normal levels. also acth is 63,4 and the limit is 64. i eat very healthy and exercise every day. for three years now i can't find a solution to my problem. i have gone to endocrinologist , dietitian and can't find a solution. i also have acne, if i don't take birth control pills i don't have period, i am very tired all day every day, it's difficult to move, i have anxiety. I did an MRI brain and pituitary and nothing was found. i also did kidneys ultrasound and nothing was found. i did blood tests for Autoimmune Diseases and they were negative. i did blood test for prolactin and it was 28 (over the limit) . mri nerves and adrenal and everything was normal. i did cortisole after 1mg tab dexamethasone and from 34mg/dl in the morning it went 3,4mg/dl and acth from 63,4pg/ml went 5,7pg/ml in the morning. FT4 1,98 ng/dl GH 4,4 ng/ml SM-C 104 ng/ml ANTI-TPO 9 iu/ml ANTI-TG 40 iu/ml CREATININE 0,60 mg/dl GnRH and TRH they don't do these tests in my country so i couldn't do them. so , i guess it's not cuhing ? what else do you think it might be ? Should i take signifor or metyrapone or something else? The problem is that i keep gaining weight. i was 55 kg and now i am 75kg. i took 8kg in a month when the doctor changed the t4 dose from 75mg to 50mg. and 5kg in 2 weeks when the doctor changed t4 from 150mg to 100mg. i exercise every day and eat very healthy (salads, fruits, vegetables, turkey and chicken). do definitely there is something wrong and i should control cortisole levels with pills. TSH 0,16 .
I did some more tests. 1)cortisol 24hr in urine 72,1mcg/g CR (previous 60mcg/g CR) 2)cortisol in blood morning 40,5mg/dl (previous 38mg/dl) 3) ACTH 80,8pg/ml (previous 63,4pg/ml) After that I did high dose suppression test with dexamethasone (8mg ) and here are the results : cortisole : 2,5mg/dl acth: 1,9pg/ml I read that : If the disease is Cushing suppression > 60 % . so I definitely have Cushing
what treatment do you suggest and what pill is safe to use during pregnancy?
doctor
Answered by Dr. Shehzad Topiwala (5 hours later)
Brief Answer:
Cushings

Detailed Answer:
It is possible you have excess cortisol production in your body.

The latest guidelines suggest using a cut off of 1.8 for blood cortisol after dexamethasone suppression tests.

Now when you say High dose 8 mg dexamethasone suppression test, did you do this for 2 days ie a total of 16 mg?

Regardless, I would strongly recommend performing the midnight salivary cortisol test, at least 2 times.

This is assuming you have the usual sleep-wake cycle of going to bed at night and getting up in morning.


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Shehzad Topiwala (10 minutes later)
8mg dexamethasone at 10 o clock and test at 8 o clock in the morning.
I have also done 1 mg dexamethasone test.
doctor
Answered by Dr. Shehzad Topiwala (8 hours later)
Brief Answer:
Follow up

Detailed Answer:
I see. Yes I noted the result of the 1 mg test too.

The 8 MG 2 DAY HIGH DOSE DEXAMETHASONE SUPPRESSION TEST (DST) is different and is supposed to be done as follows:

Again to emphasize, THIS FORMAT APPLIES TO INDIVIDUALS WHO HAVE THE TYPICAL SLEEP PATTERN OF GOING TO BED AT NIGHT AND WAKING UP IN THE MORNINGS.
IF YOU HAVE THE REVERSE PATTERN SUCH AS NIGHT SHIFTS, PLEASE LET ME KNOW SO I CAN ADVISE YOU HOW TO DO THIS TEST DIFFERENTLY.

1 FASTING IS NOT REQUIRED FOR THIS TEST

2 You will need A PRESCRIPTION FOR dexamethasone tablets.

Please make sure you take it in the right doses.

3 YOU ARE REQUIRED TO TAKE 2 MG, 4 TIMES IN A 24 HOUR PERIOD AS FOLLOWS:

9 AM, 3 PM, 9 PM, 3 AM ON DAY ONE

THEN AGAIN FROM NEXT MORNING (DAY TWO) AT 9 AM, 3 PM, 9 PM, 3 AM

THEN ON MORNING OF DAY THREE AT 9 AM YOU HAVE TO UNDERGO A BLOOD TEST FOR SERUM CORTISOL AND ACTH

4 ALSO, YOU HAVE TO COLLECT URINE IN A CONTAINER FOR 24 HOURS FROM MORNING OF DAY TWO TILL MORNING OF DAY THREE

5 THE TIMINGS FOR THIS TEST ARE CRITICAL AND SO DO NOT DEVIATE FROM THESE

So I suggest you do the midnight salivary cortisol test as well as the above HDDS test. Establishing the diagnosis of Cushings syndrome can be challenging at times.


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Shehzad Topiwala (6 hours later)
My doctor told me to take 8mg at 10 and do the test at 8 in the morning.
i have done cortisol in urine 24hr 2 times.
5 doctors confirmed that i have cushing .
what therapy you suggest? Metyrapone ? Most of them suggested this pill 2250mg per day .
doctor
Answered by Dr. Shehzad Topiwala (17 hours later)
Brief Answer:
Second follow up

Detailed Answer:
The 8 mg overnight test is also one of the alternative methods.
The one I have described is the 2 day High Dose Dexamethasone Suppression test (DST). It is well described too and is useful.

But I can understand you are anxious to get started with treatment. However one needs to be certain of the diagnosis because treatment is directed there.

Furthermore, the diagnosis just does not end at Cushings syndrome. One needs to establish whether this is ACTH dependent or not.
The 2 day high dose DST will give confirmation of this, and if fond to be ACTH dependent then even though I see your MRI of the pituitary is negative, the next step is
INFERIOR PETROSAL VENOUS SINUS SAMPLING

Sometimes the 'adenoma' producing excess ACTH is found by this test and localized to one side of the pituitary. This side is then addressed during surgery.

This is a highly sophisticated test that requires considerable expertise and experience in high volume centers. It is complex and challenging so I suggest you find an academic endocrinology/ university hospital center near you with 'Interventional Neuro Radiology' services.

The preferred treatment for Cushings disease is surgery and only then medications if required.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Shehzad Topiwala (7 hours later)
In the mri putuitary nothing was found.
so my doctor told me we can't remove the tumor since we can't see it and suggested lifetime medications, metyrapone
doctor
Answered by Dr. Shehzad Topiwala (18 hours later)
Brief Answer:
Third follow up

Detailed Answer:
As per international guidelines and best practice recommendations, Inferior Petrosal Sinus Sampling (IPSS) is a crucial next step to find which side of the pituitary has the tumor potentially to guide surgery
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Shehzad Topiwala

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Practicing since :2001

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Suggest treatment for high Cortisol levels in body, hypothyroidism and PCOS during pregnancy

Brief Answer: Cushings Detailed Answer: It is possible you have excess cortisol production in your body. The latest guidelines suggest using a cut off of 1.8 for blood cortisol after dexamethasone suppression tests. Now when you say High dose 8 mg dexamethasone suppression test, did you do this for 2 days ie a total of 16 mg? Regardless, I would strongly recommend performing the midnight salivary cortisol test, at least 2 times. This is assuming you have the usual sleep-wake cycle of going to bed at night and getting up in morning.