Adrenaline Junkies

One evening last year I received a desperate phone call from a primary care physician. His patient, a household name pop star, was planning on canceling her world tour because she had just been diagnosed with Cushing’s syndrome.

Cushing's disease is a rare hormonal disorder that occurs when the body produces too much cortisol, a hormone that helps regulate metabolism and the immune system. This overproduction of cortisol is usually caused by a non-cancerous tumor in the pituitary gland. Symptoms can include weight gain, high blood pressure, muscle weakness, and mood changes.

She had many of the more nonspecific symptoms of Cushing’s; weight gain, weakness and fatigue, anxiety and depression. Her functional medicine doctor had repeatedly checked the blood cortisol levels for the sake of completeness, and each time they were markedly elevated, leading him to diagnose her with Cushing’s. Now this lovely pop star was busy planning neurosurgery rather than dance moves.

I met her on a virtual visit, and after reviewing her history, I learned that she was on birth control. Even a newly minted endocrinologist knows that estrogen in birth control raises a protein called cortisol binding globulin which in turn leads to false positive cortisol levels. The workaround in this situation is to measure free cortisol levels in the urine (cortisol which is not bound to cortisol binding globulin). Lo and behold, her 24-hour urine cortisol levels were stone cold normal. The good news was that I reassured her she was as healthy as a horse and just needed a bit of R&R. The bad news was that I told her that her brief foray into the world of endocrinology was officially complete, and I never got to know her well enough to beg for concert tickets for my three daughters.

The more serious point here is that hormonal workups are laden with land mines. Lab results need to be interpreted with caution and with the guidance of a well-trained endocrinologist – we know where all the booby-traps are.