What's Cushing Syndrome and What's It Doing to Me in the Bedroom?
Synthesized steroid hormones are in countless prescription and over-the-counter medications, from ointments and creams to injections, ingestibles and inhalants. The treatments are used for managing symptoms and conditions such as chronic inflammation, rheumatoid arthritis and asthma.
Almost everyone will benefit from the use of steroidal medications at some point in their life. Some of the most common of these include glucocorticoid medications, which generally seek to mimic or amplify the effectiveness of your body's natural production of cortisol in response to stress and to manage a wide range of essential bodily functions. Cortisol is instrumental in activating appetite, waking you up in the morning, performing a number of subconsciously maintained vital bodily operations and facilitating the performance of conscious physical feats.
Taking glucocorticoid medications in excess and maintaining those excessive levels over time can trick your adrenal glands into producing and circulating more cortisol than your body is meant to sustain.
This can lead to a condition called Cushing syndrome.
A variety of symptoms can be associated with Cushing syndrome, which rarely develops without the outside influence of medications taken beyond a certain threshold. This threshold can vary in different people, but if you are transparent with your doctors about your use of steroid medications, they can recognize the telltale signs and symptoms of elevated cortisol levels in unhealthy amounts.
While it is less likely that topical steroids, such as creams and ointments used to treat eczema or other skin conditions, will result in elevated cortisol levels that lead to Cushing syndrome, it is still theoretically possible.
Generally known to affect women more frequently than men, symptoms such as decreased sex drive and difficulty achieving arousal are more commonly associated with Cushing syndrome in men than in women.
Cushing syndrome vs. Cushing's disease
It's important to note that Cushing's disease carries a specific distinction that separates this particular cortisol-induced condition from the more generalized disorder of Cushing syndrome.
Cushing's disease refers to the results of a pituitary tumor that produces elevated levels of the adrenocorticotropic hormone (ACTH).
ACTH is produced in the pituitary gland normally and helps regulate the production and release of cortisol from your adrenal glands, which are located just above your kidneys. ACTH can also become elevated when tumors, either cancerous or noncancerous, develop in organs that do not normally produce ACTH. While this experience is considered rare, the tumors can form in the lungs or other organs, and the elevated ACTH levels prompt your adrenal glands to produce too much cortisol.
Cortisol and Cushing syndrome
To understand what causes Cushing syndrome and Cushing's disease, it's important to understand the role cortisol plays in the body and the effects it can have when measured in elevated amounts over time.
Most cells have cortisol receptors, and your body relies on cortisol for the management of carbohydrates, fats and proteins. Cortisol also helps mitigate inflammation, regulate blood pressure and elevate blood sugar levels. It's sometimes referred to as the "stress hormone" because it works with your brain to regulate mood in response to stress. It is closely linked to your energy levels and sleep patterns, and can affect you in negative ways when circulated in your body in excessive amounts.
"Cortisol is a hormone that can lead to water retention and blood pressure changes," explained Amin Herati, M.D., director of Male Infertility and Men's Health at Johns Hopkins Medicine in Baltimore. "It can lead to increased sugar levels and, in some cases, insulin resistance from excessive cortisol. And the interplay between the sugar levels associated with excess cortisol and the insulin resistance associated can then negatively affect the circuitry of the brain called the hypothalamus-pituitary-gonadal access, and the release of signals from the HPG access influences the amount of testosterone that's produced. So guys can potentially have disrupted signaling from their hypothalamus and pituitary when they have higher cortisol levels."
Herati, a urologist with training in male infertility and andrology, further explained the relationship between Cushing syndrome and erectile dysfunction (ED): "When the sugar levels get too high, this sugar level will cause what's called endothelial dysfunction within the cells lining the arteries. Those cells, when they have too much sugar, will not release a substance called nitric oxide, and that will prevent the normal mechanisms for erectile function to occur."
Signs, symptoms and complications
Signs and symptoms of Cushing syndrome can vary. Some of the most prominent, visible results include weight gain and a round, fuller face. Weight gain most notoriously forms in the torso or the abdomen but may also be observable in the base of the neck or between the shoulders. Cushing syndrome can lead to fatigue, muscle weakness, a variety of psychological and emotional symptoms, blood pressure issues, bone deterioration leading to fractures and other conditions ranging from mild to severe.
"Classically, the things we tell people to look out for would be a 'buffalo hump,' which is excessive fat above the clavicles, right along the shoulder," Herati explained. "So [people should be aware] if they have this excess fat on the back of their neck and going down toward their shoulders, if they have stretch marks—oftentimes they're purple in color, those are called cutaneous striae—if they have more bruisability, if they get bumped anywhere [and] they get black and blue."
All of these symptoms might be the result of Cushing syndrome, though not all patients will display each one.
"So the other thing that we see is oftentimes called truncal obesity, which means that their trunk or their abdomen is obese but they have very skinny arms and legs associated with it," Herati said. "So they get thin arms, thin legs, but an obese abdomen."
These are the more commonly visible physical symptoms of Cushing, but the condition can affect men and women in other physical or behavioral ways as well. Women often experience increased hirsuteness, or unusual hair growth, along with irregularity in their menstrual cycle.
Since Cushing syndrome is so closely connected to the body's stress response, it can cause a person's mood to fluctuate or appear erratic to outside observers. Especially in men, these psychological and emotional effects can manifest in the form of altered or impaired sexual function. Mostly, this means men who sustain elevated cortisol levels over time are likely to experience decreased libido, particularly if the root cause of Cushing is pituitary-based. However, ED can also occur as a result of cellular "miscommunication" taking place, as Herati mentioned, or when Cushing leads to type 2 diabetes, which has a well-documented association with ED.
Noncancerous adrenal gland tumors and adrenal cancers can also cause Cushing syndrome.
Treatment options and other considerations
The most common treatment method for Cushing syndrome is to simply taper off the use of glucocorticoid medications to allow adrenal production of cortisol to return to normal.
In the case of tumor-associated Cushing syndrome or Cushing's disease, surgical removal may be necessary, though radiotherapy has been known to be effective in cases where surgery has not achieved the desired results. Certain medications can be helpful in reducing cortisol levels, though this may not always be sufficient in eliminating the syndrome altogether.
Pituitary tumors causing Cushing's disease can be removed surgically, though this procedure does not always solve the problem, either. In such instances, radiation focused on the pituitary gland may be an option.
In more severe cases, doctors may need to remove the pituitary or one or both adrenal glands. Removal of these glands may require supplemental cortisol or ACTH treatments to be taken for several months or for the rest of the patient's life, depending on whether one adrenal gland or the pituitary remains intact.
One lesser-known potential consequence of Cushing syndrome should raise concern for men unfortunate enough to be so wise in the ways of urological pain. Herati cautioned about a particular link he and his team have observed in their work at Johns Hopkins Hospital and the James Buchanan Brady Urological Institute.
"The other thing that we see from a urology perspective is that the bone breakdown, or bone loss, associated with Cushing syndrome can lead to kidney stones," he said.
Herati said some male patients suffering from Cushing syndrome have two characteristics in common: the classic symptoms—purple lines on the abdomen, thin arms, thin legs and truncal obesity—and "a bunch of kidney stones."
If you've ever passed a kidney stone or even heard someone tell the tale of doing so, you'll probably read the instructions on your next package of glucocorticoid medicine at least twice.
And if you fear you may have Cushing syndrome and it's affecting your sexual function because of low-T or ED, consult your primary care doctor or a urologist for advice and treatment.