And It's About Time There Was Some Support For Cushing's!
Listen to the January 29, 2009 interview here!
Dr Ted Friedman will be our guest in the weekly Interview/Podcast series.
We will take written questions first. If there is time at the end, we will take callers.
Short Bio:
Theodore C. Friedman, M.D., Ph.D. has opened a private practice, specializing in treating patients with adrenal, pituitary, thyroid and fatigue disorders. Dr. Friedman has privileges at Cedars-Sinai Medical Center and Martin Luther King Medical Center. His practice includes detecting and treating hormone imbalances, including hormone replacement therapy. Dr. Friedman is also an expert in diagnosing and treating pituitary disorders, including Cushings disease and syndrome.
Dr. Friedman's career reflects his ongoing quest to better understand and treat endocrine problems. With both medical and research doctoral degrees, he has conducted studies and cared for patients at some of the country's most prestigious institutions, including the University of Michigan, the National Institutes of Health, Cedars-Sinai Medical Center, and UCLA's Charles Drew University of Medicine and Science.
He has a private practice in Los Angeles specializing in hard-to-diagnose and treat cases of adrenal, pituitary, and thyroid disorders. He is the father of three children. Dr. Friedman lives in California.
He's the "Dr House" of endocrinology. He loves complicated cases and is an outstanding diagnostician.
He also has a PhD in pharmacology.
Kate (Fairley) and Dr. Ted Friedman on National Geographic TV, September 2007/
Read Dr. Friedman's First Cushing's Help and Support Guest Chat
November 11, 2003 »
Dr. Friedman's Second Guest Transcript, March 2, 2004 »
by Theodore C., M.D., Ph.D. Friedman (Author), Winnie Yu (Author)
If you have a thyroid condition, you are not alone. An estimated 13 million Americans suffer from thyroid disease. The Everything Health Guide to Thyroid Disease, cowritten by acclaimed thyroid specialist, Theodore C. Friedman, is the authoritative handbook you need to help you live with this disease. You'll learn about:
Complete with a glossary, additional resources, and even a section on thyroid disease in children, The Everything Health Guide to Thyroid Disease is the complete guide for everyday healthy living.
1. Patient post BLA 2 years ago has and ACTH of over 2000 and rising, and the patient has muscle weakness, hyperpigmentation, MRI comes back clear (Cushing's diagnosis was ACTH secreting corticotroph hyperplasia and MRI before surgery was also "clear"), IPSS confirmed cells are still there. Is this Nelson's, and should any treatment be done? If so, what? Thank you.
2. Can something other than cushings cause high ACTH's?
1. My Mom (age 66), has been diagnosed thru and adrenal CT as having 3 adrenal tumors that involve both glands.
- Each tumor is approximately 1-2 cm x 2cm,
- They demonstrate a Hounsfield unit of less than 5 on the noncontrast.
- The arterial phase showed Hounsfield units between 41 & 59 with greater than 50% washout on 10 min delayed imaging.
She had a hyper-tension crisis several months ago and I asked her family doc to run a plasma free metaephedrine test. It came back 100 pts higher than normal. I asked for it to be run a 2nd time by another lab and it came back 50 pts higher than normal. Both of these were done while she was on 3 blood pressure meds.
Her family doc doesn't feel like any additional testing should be done, but my gut feeling is that he's making too light of these findings. What do you recommend?
1. why would someone with a BLA, no dhea replacements, and low testosterone get a 5 oclock shadow everyday?
2. What is the long term prognosis for people who have had a BLA? What are the death rates down the road for people who have had BLA's compared to people who have not?
2011: What causes a person to have high levels of CBG?
If a patient has high CBG, does this change how you evaluate their labwork (UFCs, saliva tests, etc)?
2011: Good one, I'd also like to add to that question, if your CBG is high, how does it affect treatment? If you have a BLA, will the hydro build up in your system the same way Total cortisol does causing "cushings symptoms"?
1. Is cortisol measurable in ear wax?
Is cortisol measurable in body fat, esp hump, supraclavicular fat pads or belly fat? Say via punches?
What is going on with research into hair and measuring cortisol?
What is going on with measuring cortisol in sweat (studies published seem to express hope of this working)?
My question is really are the measurements available and are they diagnostically relevant.
2. If I understand correctly: surgeons and physicians, endos, etc. who treat pituitary and adrenalectomy patients look at cortisol in blood levels and not urine and saliva POST OPERATIVELY. Why?
3. What is the relationship between thyroid and cortisol?
1. For those of us who are testing and testing and testing for cushings, I can envision my tumor sending off shoots and turning into hyperplasia. What is the liklihood of the tumor growing or developing hyperplasia for those that seem to have to test for a long time?
2. Some doctors are predicting that SOM 230 will be the new conventional treatment for Cushing's Disease. The trial has only included patients who achieved high ufc's on several occasions (untainted by any normal tests) Do you believe it will be an effective treatment for cyclical or intermittent Cushing's as well?
3. Probably the most important question for me....can you have a few highs like a midnight serum of 11.8 and not have cushings?
4. With 2 out of 3 salivary tests high (one being more than 3 times normal range) one out of 5 UFCs high (50.8 with a range of 4-50) not suppressing on the dex test (cortisol 7.8 after dex) And a verified pituitary tumor of 7mm #1)What should the next step in this process be? #2) Would it be safe to lean toward a cyclical Cushing's diagnosis? #3) What tests SHOULD NOT be performed?
5. Are there conditions other than Cushing's that would affect the diurnal pattern of cortisol?
6. In your experience, is it common for post-op (cure?) Cushing's sufferers to suddenly acquire new allergies? (asks the woman who is now allergic to cinnamon)
7. What is the role of Cortisol Binding Globulin in testing and diagnosis of Cushing's Disease?
8. Do you think that preimplantation genetic testing can be a useful procedure for someone who is suspected of having familial Cushing's, and doesn't want to pass it on to their child? Is there just one gene responsible for familial Cushing's? What are your thoughts on preimplantation genetic testing?
9. Are the terms 'end-stage' and florid Cushings synonymous?
10. Is there a standard description (Stage I, Class I, etc). to describe the progression of Cushings Disease (meaning from a pituitary source)?
11. Have you seen a patient with Cushing's with diagnosed hypertrophic osteoarthropathy and if so does the hypertrophic osteoarthropathy resolve after the Cushing's is addressed?
1. Is there any group of experts who work with Cushing's syndrome/disease (including complicated/cyclical patients), working on a consensus statement or guideline to identifying and treating these patients to help the medical community better understand this disease and possibly identify patients sooner. Is there enough published evidence for a guideline to be developed?
2. What is the current role of IPSS in diagnosing Cushing's disease, particularly in cyclical Cushing's patients?
3. It seems most cyclical cushing's patients have tumors that are of a "snotty" consistancy. This makes it difficult if not impossible for complete removal of the tumor, resulting in lower cure rates. Can a form of chemotherapy be invented to kill off any tumor cells that are left after surgery?
4. Some doctors say that in cyclical Cushings the 'tumor' turns off and on thus causing its cyclical nature. Question: In your opinion, what causes cylical Cushings if a person has a confirmed tumor? Same question, however, what if the patient has confirmed hyperplasia?
5. Some doctors say that in cyclical Cushings the 'tumor' turns off and on thus causing its cyclical nature. Question: In your opinion, what causes cylical Cushings if a person has a confirmed tumor? Same question, however, what if the patient has confirmed hyperplasia?
1. If a person goes without sleep for at least 24 hours, followed by 2-3 hours of sleep, and repeats the process on consecutive nights, could they inadvertantly "reset" their internal clock and thus disrupt their diurnal rhythm for an extended time?
2. If this is possible wouldn't their cortisol levels be flipped around and they would have high midnight serums and low daytime serums?
1. Is it true that endocrinology student doctors are at an all time low as a number and as a percentage of med students?
2. Does he know any good doctors in Melbourne Australia? Im desperate!
Also, do you believe that "natural" supplements such as those sold at vitamin stores that are marketed for growth hormone production can be beneficial for those whose insurance denies gh, and whom are severely deficient?
What results were you seeing from the cortisol hair samples in comparison with diagnoses of patients? Do you think this test will be beneficial in the future?
Can you give me an easy to understand analogy to the HPA axis, feedback loop and negative feedback loop?
Do all of the hormones that use the hypothamalic - pituitary axis have feedback loops and negative feedback loops? If not, which ones?
What role does hyperplasia play in being cured or not cured after pituitary surgery and why? Can you explain exactly what hyperplasia is?
1. Are there instances when high cortisol levels can not be captured, but a hypopituitary patient with a validated tumor present would require surgery for tumor removal?
For those Cushing's patients with chronic pain, and with proper legal and medical authorization, what is your opinion on marijuana use in the un-diagnosed or relapsing "Cushie?"
1. Are there any studies of 'the encapsulated' pituitary microadenomas responding to therapies like those used to collapse varicose veins (injection of substance into vein and vein collapses on self and withers away)?
2. Do I risk having unreadable pituitary MRIs the more dental implants I get? I am losing teeth at an alarming rate.
1. What are the odds of dying during pituitary surgery?
2. If you have already had unsuccesful pituitary surgery and you are moved to BLA what, if any, are the consequences of any residual tumor on the pituitary?
1. What does a low or low-normal CBG mean and what does a high or high-normal CBG mean in relation to test results of blood cortisol, urine tests (UFC's an d 17-OHC), and saliva.
2. What test are you using to determine GH Deficiency since GHRH is no longer being made?
1. Can you be Hyperthyroidism and Hypothyroidism at the same time?
2. What are reasons that your TSH would continue to rise even though you are increasing your thyroid/Synthroid doseage from 88mcg, 100, 125 to 150mcg in one year? with TSH doubling at the end of the year?
3. After thyroidectomy and radiation, are there side effects that can cause salivary gland problems?
4.Is it possible for a person who must take thyroid replacement hormone to sometimes be able to convert the T4 to T3 and sometimes not?
What would cause this? What would make a persons TSH soar into the 140's and dump below 2 in less than a week? This person had a thyroidectomy 18 years ago and 3 known pituitary tumors and never has had level thyroid numbers last more than 2 months.
Regarding Hypothyroidism:
1. Does taking iron supplements, and/or topical oestrogel or bio-identical oral HRT, lower the available thyroid hormone meds/utilization in the body (ie. binding to TBG)?
Is it possible for hypothyroid symptoms to come back in this scenario if the patient was previously feeling euthyroid with medication?
If so, does this show up as lower levels of Free T3 and Free T4 in the blood or does it only show up physiologically in the patient?
If this change only shows up as in the patient symptoms and not in blood tests, then what is the treatment protocol?
If iron or calcium is taken at a different time than thyroid meds, does that eliminate the potential for lowered utilization of thyroid meds and interactions, even at high doses of these supplements?
Can bio-identical progesterone pills or topical progesterone and/or testosterone cream cause the same effects? What other supplements (like calcium?) or other meds, if any, have the potential to bind with thyroid meds and cause less to be utilized in the body?
2. Why would someone have an elevated TSH, with mid-range normal T3 an T4 and zero antibodies? Could this have a relationship to Cushing's?
3. Do thyroid meds lower cortisol levels? If so, could this make it difficult for one to show high cortisol in their tests, even if that person has Cushings?
4. Can high cortisol levels in the body (ie. from Cushings) mask hyperthyroid symptoms? If so, in what ways?
5. Can being properly medicated on thyroid meds mask the physical signs of Cushings?
1. Do you treat patients with pineal gland tumors?
2. Why does diabetes get all the attention?
3. Do you believe there is a chance that the ubiquitous artificial light we are exposed to causes some disruption of the pineal, pituitary or other glands?
4. Do fictional shows like "House" and documentary shows like the one that featured you, "The Science of Obesity", help develop interest in endocrine research?
5. How can we help further endocrine research?
6. Why are so many doctors (other than you) so dismissive of patients symptoms?
(similar) How do we get the understanding and respect we deserve from Dr.s?
7. What can we do to help our doctors figure out complex medical issues?
8. What changes would you like to see in the field of medicine?
9. What would you as a doctor like the public to know?
10. What changes would you like to see in the field of medicine? or: What have been the biggest changes you've seen in the field of medicine?
11. What is the relationship between a high stress childhood, PTSD and a burned out endocrine system?
12. Do we all have Adrenal Fatigue? If so what can we do for that?
THANK YOU for your attention to the Cushings and pituitary disease community.
