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Theodore C. Friedman, M.D., Ph.D.
  About Dr. Friedman

MaryO: Tonight's guest, Theodore Friedman, M.D., Ph.D., is in private practice specializing in adrenal, pituitary, thyroid and fatigue disorders. His practice includes detecting and treating hormone imbalances, including hormone replacement therapy.

Dr. Friedman is also an expert in diagnosing and treating pituitary disorders. His 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.

Please remember, everyone, that the information you're receiving here is for that purpose alone, information. It's not intended as a substitute for a visit to your own doctor.

Welcome to Cushing's Help and Support, Dr. Friedman!

Theodore Friedman, M.D., Ph.D.: Remember that I cannot diagnose or treat someone without seeing them. I recommend going to a good endocrinologist with expertise in Cushing's and I am accepting patients. Please visit my website at

Shauna: Hi Dr. Friedman, I had a general question. What is the failure rate of bilateral adrenalectomies? If there is any, what is the main cause, i.e. extra adrenal tissue, missed adrenal tissue, etc?

Theodore Friedman, M.D., Ph.D.: It's super rare - the main cause of failure is adrenal rest tissue , we had 1 patient where the adrenal rest tissue was found in the liver. In general, bilateral adrenalectomy is an excellent option when pituitary surgery fails.

DCrosley: I was diagnosed with macronodular hyperplasia. I had a BLA (bilateral adrenalectomy) January 2002. I also have history of right lobe thyroidectomy with normal labs now. No HRT (hormone replacement therapy) now. I have uterine fibroids. I'm still fatigued, muscle and back aches and pains lots of hair growth on chin. How is macronodular hyperplasia different, or is it?

Theodore Friedman, M.D., Ph.D.: The symptoms of macronodular hyperplasia are usually the same as other forms of Cushing's. The treatment is usually bilateral adrenalectomy, although occasionally the original cause is pituitary.

Meriftr: What tests would you order for patients who have continuous high UFCs, but normal dex suppression?

Theodore Friedman, M.D., Ph.D.: I'm finding that dex suppression is very unreliable in mild Cushing's. If your UFC (Urinary Free Cortisol) is high and your symptoms and signs support Cushing's, I would proceed to figuring out where the Cushing's is coming from. Since you already suppress to dex, your source is probably your pituitary.

Meriftr: I was diagnosed with a pit tumor, possible adrenal mass.

Theodore Friedman, M.D., Ph.D.: Where are you in your workup? had a pituitary MRI? Are your ACTH low or normal/high? If normal/high the source is probably your pituitary.

Meriftr: Pituitary MRI, adrenal MRI (recommended a CT scan)...ACTH normal...cortisol always higher than normal. I have a 9.2*7.7mm tumor on the anterior pituitary.

Theodore Friedman, M.D., Ph.D.: What about the pituitary MRI? We are now doing dynamic MRIs which is a cross between regular MRI and a PET scan of the pituitary. We are finding its picking up small tumors.

CrazyFrenchGrrl: No diagnosis for me, just lots of symptoms. Cushing's? I suppressed on the overnight dexa test. I'm being referred to a neuroendo at MGH (where I work); first appointment is 11/18. What test(s) should I ask my endo to perform? I ONLY had overnight dexa suppression test.

Theodore Friedman, M.D., Ph.D.: At least 3 24 hour urines for UFC and 17-hydroxy steroids and 3 11 PM salivary cortisols. In my 14 patients with confirmed Cushing's all had a least 1 normal UFC and 1 normal salivary cortisol so I think all patients are periodic and a normal test doesn't exclude the diagnose.

CrazyFrenchGrrl: Most likely pituitary in nature due to suppression on dexa overnight?

Theodore Friedman, M.D., Ph.D.: Yes, it is most likely to be a pituitary source-if one of those tests is positive.

CrazyFrenchGrrl: Then from there, if there's anything abnormal I should advocate MRI? Also: is insurance paying for the dynamic MRIs these days?

Theodore Friedman, M.D., Ph.D.: I haven't had any trouble with insurances and the dynamic MRI/

CrazyFrenchGrrl: Can I rule out the adrenal?

Theodore Friedman, M.D., Ph.D.: I would measure an ACTH to help determine if its adrenal or pituitary.

Guest38: Does Cushing's have any impact on liver or kidney function?

Theodore Friedman, M.D., Ph.D.: Occasionally you get what is called fatty liver with Cushing's and your LFTs (liver function tests) go up. You could also get kidney stones causing renal tests to go up, but that is rare.

Pixie-Dust: If stretchmarks covering 90% of the body are not related to weight gain, pregnancy, growth, or Cushing's, even though other Cushing's symptoms are present, what else can be the cause?

Theodore Friedman, M.D., Ph.D.: Probably its Cushing's.

Pixie-Dust: if doctors refuse to test for Cushing's what should I do

Theodore Friedman, M.D., Ph.D.: Pixie-Dust should come see me

Jayne: Can you explain why my 24 hour urine cortisol levels are high? I do not have adrenal glands, I'm 35 weeks pregnant taking 30 mg hydrocortisone per day. Test results were 143.8 and 95.

Theodore Friedman, M.D., Ph.D.: Yes. Almost everyone on cortisol replacement has high UFCs. A better test to monitor cortisol replacement is the 17-hydroxy steroids.

MaryO: Thanks, Dr F - I think the immediate world comes to see you! I'm curious - how many people here are patients of Dr Friedman? I know that there are a LOT of people on the message boards who are.
KathiK: me
sally: me
Guest38: me (Susan M)
kellyann: me
cindylou: my daughter
Teresa: I am
JenS: I have appointment in January 2004

Lynne: With cyclic Cushing's, can a dex-crh test catch it when you're in a "low" cycle?

Theodore Friedman, M.D., Ph.D.: Probably not. You need to be in a high phase for all tests. My suspicion is that a dex-crh will pick more borderline high cases.

Classisassi43: Can a benign tumour other than the pituitary, adrenal or lung cause Cushing's? I have a lifetime weight problem, most Cushing's symptoms, mild elevated UFC, I was born with tumour exterior head. I will be coming to see you.

Theodore Friedman, M.D., Ph.D.: Yes, ectopics can be in other places like the pancreas and thymus. You could have Cushing's unrelated to your head tumor.

KathiK: Will removal of the pituitary tumor have any effect on Hashimoto's Hypothyroidism or the nodules on the thyroid?

Theodore Friedman, M.D., Ph.D.: Maybe. High cortisol "treats" Hashimoto's, so removal of your tumor in a sense may make it worse. But high cortisol also suppresses TSH, I would recommend careful thyroid testing after surgery with adjustment in thyroid medications.

LolaH: I am, at this point, undiagnosed. My endo. is sure I don't have Cushing's. If I have it, just going by the physical symptoms I've observed, I would have had it for close to 25 of my 31 years. After that long, symptoms would be somewhat severe, I'd think, and surely it would be enough to show up on tests. Would you agree? I don't have severe symptoms at all and what I do have (stretch marks which faded years ago), round face, some pinkness to my complexion.

Theodore Friedman, M.D., Ph.D.: Lola, I just saw a patient that probably had Cushing's for 26 years because, she like most patients, is periodic, during her normal periods, her body has a chance to recover and the symptoms improve-I would try to get tested when you are high.

LolaH: How would I know when that is?

Theodore Friedman, M.D., Ph.D.: I would measure 3 UFCs and 17hydroxysteroids and 3 night time salivary cortisols.

Traci: My wife is at school tonight so I am here to ask our question: She is obese and carries her weight in her mid section. She also has straie and a buffalo hump. She has had three blood tests come back showing her ACTH levels are below normal and she just had an MRI that shows a 3mm adenoma. Her doctors say she is fine and there is nothing that they need to do. They want to wait for the tumor to grow and begin putting pressure on the pituitary gland.

Theodore Friedman, M.D., Ph.D.: I think the key is diagnosing and treating Cushing's early.

Traci: Okay would you be willing to treat her?

Theodore Friedman, M.D., Ph.D.: Sure.

Kathleen: I have a left adrenal tumor, but diagnosed with Metabolic Disease, possibly Bi-Polar, but feel Cushingoid. My Endo said 1 urine analysis in a couple weeks. Then I guess I'm done. I have high blood pressure, mid-section weight, etc. I can't get them to test!

Theodore Friedman, M.D., Ph.D.: It sounds like Cushing's to me. Metabolic disease is a diagnosis of exclusion. I would collect the urines and salivary cortisol.

Kathleen: How do I get more tests?

Theodore Friedman, M.D., Ph.D.: Come see me or have your doctor order them. Make sure you send your email to

JenS: How best to show a doctor that we are sick, not fat? They ignore all other symptoms - hump, straie - and just concentrate on the fat. How to get them to work on the underlying problem?

Theodore Friedman, M.D., Ph.D.: Find a good doctor. You are right. Other diseases give you obesity. Only Cushing's gives you rapid weight gain, trouble sleeping, fatigue and other symptoms.

JenS: Can't do anything to educate a moderate one?

Theodore Friedman, M.D., Ph.D.: Try, but most doctors have an outdated notion of Cushing's.

MaryO: At the recent CUSH Convention, the keynote speaker said that a "cured" patient was never safe from recurrences. I thought after the 10 year mark or so, that the likelihood of a recurrence would be very small. What are your thoughts, please?

Theodore Friedman, M.D., Ph.D.: Yes, I think recurrence is rare after a few years.

MaryO: Whew! Thanks :)

Teresa: What can cause An IPSS (Inferior Petrosal Sinus Sampling) test to have conflicting results?

Theodore Friedman, M.D., Ph.D.: NOT having high cortisols at the time of the sampling (but you did)

Teresa: Is it just because I am difficult then?

Theodore Friedman, M.D., Ph.D.: Teresa, you are difficult but we'll figure you out and get you on with your life.

CindyLou: How many cortisol test have to come back high before a patient can be completely diagnosed with Cushing's and have surgery?

Theodore Friedman, M.D., Ph.D.: With a convincing signs and symptoms, I'd say 1. It depends on how high and what test. G

SharonW: How accurate is the sinus sampling test?

Theodore Friedman, M.D., Ph.D.: It's only to distinguish between pituitary and ectopic and should not be used to diagnose Cushing's.

Desley: Hi Dr Friedman, I wrote to you a few weeks ago, All my UFCs have been normal, two low dose dex test normal, NO MRI - because of no bio-chemical evidence. I have appointment with Prof. Ken Ho, on Thursday, What tests should be done?

Theodore Friedman, M.D., Ph.D.: I would do 17hydroxysteroids and night time salivary cortisols. Try to get them when you are high.

Symptoms of high include weight gain, trouble sleeping, acne
Symptoms of low (don't collect then) include nausea, vomiting, joint pain

Guest273: I am an Addison's patient who has Cushingoid symptoms from too high dose (of cortisone) at illness. How long for weight gain, BPs etc to return to normal? I'm still tapering.

Theodore Friedman, M.D., Ph.D.: Most Addison's patients should be on no more than 25 mg of HC (hydrocortisone) a day. The problem is doctors forget about giving florinef and instead give too much cortisol. Too much cortisol is the same as Cushing's.

Guest273: I am trying to get to 1mg dexamethasone.

Theodore Friedman, M.D., Ph.D.: You should get a standing renin to monitor florinef. You may do better on hydrocortisone.

Guest273: I did worse on it. Will I be fat forever?

Theodore Friedman, M.D., Ph.D.: No. I think if you are on the right dose of florinef, tapering the dexamethasone is not hard.

Kristy: In your article discussing Pseudo Cushing's, You mention a loperamide test. For those undergoing differential diagnosis, is this test really done and where? Ditto with IL-6.

Theodore Friedman, M.D., Ph.D.: I think Pseudo Cushing's is much less common than when I wrote that article. It has to do with the new UFC test. The old UFC test was elevated in patients without Cushing's, while if you are high on the new UFC tests, you probably have Cushing's. Therefore, I don't think you need IL-6 or loperamide tests.

JenS: What is the difference between the old and new UFC test? How do we know which one we had?

Theodore Friedman, M.D., Ph.D.: The old one has a normal range of 20-90ish, the new one 10-40ish. The new one should say by HPLC or mass spec, the old one by ria.

DCrosley: Do you think my residual fatigue and muscle aches can still be Cushing's related being 22 months post-op? I'm on 25mg cortef qd. or do I need to look for another source, pituitary? Or completely different source?

Theodore Friedman, M.D., Ph.D.: What kind of surgery did you have?

DCrosley: BLA (bilateral adrenalectomy)

Theodore Friedman, M.D., Ph.D.: Its probably due to wrong dose of florinef, you should also be on DHEA and maybe testosterone.

Pixie-Dust: I am a broke college student in Oklahoma and I would love to come see you to evaluate me. Would it be possible to communicate through e-mail first with scanned test results and pictures?

Theodore Friedman, M.D., Ph.D.: No. I cant diagnose or treat someone until I see them, malpractice rules. Try to find a good local doctor.

Leslie: I had a pituitary tumor removed 5 years ago, estimate having tumor for 15+ years. Docs say PCOS, but are not testing for it. Is there anything the we should be looking at or doing to work on fatigue, depression, and difficulty losing the weight? And can you come back to chat again, as we have so many questions to ask?

Theodore Friedman, M.D., Ph.D.: You need to have your pituitary replacement optimized: thyroid estrogens, testosterone, GROWTH HORMONE

I'd be happy to do the chat again.

MaryO: Terrific! Thank you!

Chrisa33321: If I feel I'm cyclic and I am in a low cycle when I have my dex-crh test and it comes back negative what would you suggest doing next?

Theodore Friedman, M.D., Ph.D.: I would start with UFC/17OHS and salivary cortisols when you feel high.

DebMV: Dr. Friedman, we've had many ask the benefits of Trans-nasal surgery over Transsphenoidal. We've also have been told by another doctor there is no benefit, but this seems to be opposite of what we are reading from our other board members. What are your thoughts, please? Both regarding the surgery itself as well as post-surgery recovery. ... and can we have you cloned???

Theodore Friedman, M.D., Ph.D.: The most important thing is to find a good surgeon and endocrinologist, both that you can work with. I do recommend endoscopic surgery. And I don't believe in cloning. It would confuse my children to have two daddies!

CrazyFrenchGrrl: Status post open heart surgery 12.24.01 for repair of 2 atrial septal defects (congenital). How could this affect diagnosed and subsequent treatment of Cushing's?

Theodore Friedman, M.D., Ph.D.: I don't think it should affect either. Make sure the surgeon knows about it, but I don't see a problem.

Jane: If you cycle, how can you tell you are "high" for testing? thanks.

Theodore Friedman, M.D., Ph.D.: High symptoms include weight gain, acne, trouble sleeping, higher blood pressure, diabetes if you have it.

CJA: What do you know of the drug Avandia for reducing cortisol levels? As compared to Ketoconazole? What success do you know of? And where are you located?

Theodore Friedman, M.D., Ph.D.: Yes. My colleague in LA, Dr. Heaney showed in animals studies that Avandia reduces cortisol and shrinks tumors. There is anecdotal evidence that it helps in patients, but it doesn't work great. I still recommend surgery. I'm in LA.

Classisassi43: When coming to see you from out of state, how long should I be there for tests? Any overnight hospital? Can I do cortisol saliva tests myself at home with a reliable accuracy?

Theodore Friedman, M.D., Ph.D.: I see patients on Wednesday night and would plan on staying until Sunday or so. I use ACL FOR THE salivary cortisols.

Sally: Is it normal to suddenly have all of your symptoms rapidly worsen? The past month everything has gone downhill very quickly.

Theodore Friedman, M.D., Ph.D.: Yes. That is the nature of periodic Cushing's, that it can get worse during a high period.

MaryO: Thank you so much, Dr. Friedman, what a wonderful service you're doing for so many Cushing's patients. I do hope you'll join us again for another chat!

Dr. Friedman, thank you for joining us tonight to help sort through our many Cushing's questions and concerns. Remember to visit Dr. Friedman's Web site at

Read Dr. Friedman's Second Guest Transcript, March 2, 2004 »
Read Other Transcripts »

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