Woman’s glucocorticoid-induced Cushing’s syndrome misdiagnosed
Adrenal insufficiency led doctors to diagnosis of perimenopause
A woman developed therapy-related Cushing’s syndrome after prolonged treatment with a glucocorticoid for osteoarthritis, which is marked by joint damage and degeneration, a case study reports.
As a result, the woman developed adrenal insufficiency and was misdiagnosed with perimenopause. In adrenal insufficiency, the adrenal glands become unable to produce sufficient amounts of steroid hormones, including cortisol.
The findings underscore the need for “careful physical and laboratory assessment” and how stopping and replacing glucocorticoids can improve both “adrenal and ovarian function,” the researchers wrote.
The report, “Iatrogenic Cushing Syndrome and Adrenal Suppression Presenting as Perimenopause,” was published in JCEM Case Reports.
Cushing’s syndrome occurs when there’s too much cortisol in the body. Cushing’s disease is a relatively common form of Cushing’s syndrome where high cortisol levels are brought on by a tumor in the pituitary gland in the brain. Prolonged exposure to steroid medications that are similar to cortisol, or glucocorticoids, can also trigger Cushing’s. This is known as iatrogenic or treatment-related Cushing’s. Injecting glucocorticoids into a joint’s synovial space, that is, the area between the bones that’s filled with synovial fluid, is a standard treatment for osteoarthritis.
Because glucocorticoids act like cortisol, high levels of them can make it seem like there’s enough cortisol in the body, causing the adrenal glands to stop producing the hormone and leading to adrenal insufficiency. Just as high cortisol levels can negatively impact health, so too can adrenal insufficiency.
Therapy-induced Cushing’s misdiagnosed
Researchers in the U.S. described the case of a woman, 43, who developed iatrogenic Cushing’s after being misdiagnosed with perimenopause, the early signs of transition into menopause.
The woman had a complicated clinical history, including diabetes and osteoarthritis, among other disorders. She was referred to a reproductive endocrinology consultation due to signs of perimenopause, including hot flashes, and irregular or missing periods. The woman had given birth to three babies, but developed gestational high blood pressure in her last pregnancy. Besides irregular periods, in the past five years, she had gained weight, and developed diabetes and high blood pressure.
She failed to mention that she was receiving glucocorticoid injections at her first consultation.
A physical exam confirmed she was overweight, had an excessive buildup of fat behind the neck, a round, red face, and purple stretch marks across the abdomen and arms, all typical symptoms of Cushing’s. She also needed a cane to walk and had severe muscle weakness in both legs.
A pelvic ultrasound revealed no masses or polyps in her uterus, but the woman did eventually inform clinicians that for the past five years she’d been receiving injections of the glucocorticoid triamcinolone in the joints of both shoulders, hips, and knees, every two to three months.
Blood work showed signs of adrenal insufficiency, including abnormally low levels of cortisol and adrenocorticotropic hormone (ACTH), a hormone that stimulates the adrenal glands to produce cortisol. She declined to have more tests to confirm an adrenal insufficiency diagnosis.
The woman was started on hydrocortisone as a glucocorticoid replacement therapy. It was gradually reduced after 16 months.
Within six months of stopping glucocorticoid injections, the woman’s hot flashes stopped and her menstrual cycles became regular. She also lost weight, her stretch marks were markedly reduced, and she was able to walk without assistance. Fourteen months after glucocorticoid cessation, blood work confirmed partial adrenal function recovery. Two months later, her ovarian function was fully reestablished.
“Steroid use may lead to Cushing’s syndrome and subsequent adrenal insufficiency,” wrote the researchers, who said “treatment of adrenal insufficiency … allows for subsequent return of adrenal and ovarian function.”
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