Cushing Syndrome

What is Cushing Syndrome?

Cushing syndrome is a condition that develops when the body is exposed to abnormally high levels of cortisol for a prolonged period. Cortisol is a hormone produced by the adrenal glands, which are located above the kidneys. It helps regulate blood pressure, blood glucose, metabolism, inflammation and the body's response to stress.

Prolonged cortisol excess can affect several systems of the body. Common effects include weight gain, muscle weakness, easy bruising, wide purple stretch marks, high blood pressure, high blood glucose, bone loss and changes in mood.

What are the Types of Cushing Syndrome?

Cushing syndrome can be broadly classified according to whether excess cortisol exposure comes from medication or excessive hormone production within the body. The common types of Cushing syndrome are as follows:

What are the Symptoms of Cushing Syndrome?

Symptoms of Cushing syndrome develop because prolonged cortisol excess affects metabolism, muscles, skin, bones, blood vessels and other body systems.

The common symptoms of Cushing syndrome are as follows:

Other characteristic features can include increased fat around the neck, a fatty deposit between the shoulders and slower growth in children. Women may develop excess facial or body hair and irregular or absent menstrual periods. Men may experience reduced fertility, decreased sexual interest or erectile dysfunction.

Children with Cushing syndrome may gain excess weight while growing more slowly in height. This combination can be an important clinical clue.

Not every person with Cushing syndrome develops all of these symptoms. The combination, progression and unusual nature of symptoms are important when deciding whether further evaluation is required.

What Causes and Risk Factors of Cushing Syndrome?

Cushing syndrome develops because the body is exposed to excessive cortisol or cortisol-like glucocorticoids. The main causes include:

• Long-term corticosteroid use: Prolonged exposure to glucocorticoid medicines is the most common overall cause of Cushing syndrome.

• Pituitary tumour: An ACTH-producing pituitary tumour can stimulate the adrenal glands to produce excessive cortisol. This causes Cushing syndrome.

• Ectopic ACTH-producing tumour: A tumour outside the pituitary can produce ACTH and increase cortisol production.

• Adrenal tumour: An adrenal tumour may produce cortisol independently of ACTH.

• Other adrenal disorders: Certain adrenal abnormalities can also result in excessive cortisol production.

While the underlying cause determines how Cushing syndrome develops, certain factors can increase a person's risk of developing the condition:

• Long-Term Corticosteroid Exposure: People who use glucocorticoid medicines for prolonged periods may have a higher risk of developing exogenous Cushing syndrome. The risk can increase with higher doses and longer treatment duration.

• Long-Term Steroid Treatment: People receiving prolonged corticosteroid treatment for conditions such as asthma, rheumatoid arthritis, autoimmune disorders or after organ transplantation may have greater exposure to glucocorticoids.

• Pituitary or Adrenal Tumours: Pituitary or adrenal tumours can cause endogenous Cushing syndrome. These tumours are not usually considered preventable risk factors, but identifying them early can help guide appropriate treatment.

Diseases Similar to Cushing Syndrome

Several conditions can cause symptoms that overlap with Cushing syndrome. These include obesity, polycystic ovary syndrome (PCOS), metabolic syndrome and certain mental health conditions.

The distinction is important because the underlying causes and treatment approaches are different. The table below distinguishes Cushing syndrome from diseases similar to it:

Cushing Syndrome vs. PCOS vs. Obesity vs. Metabolic Syndrome

Because several symptoms overlap, Cushing syndrome should not be diagnosed based on appearance or individual symptoms alone. Appropriate biochemical testing is required when clinical suspicion is significant.

What are the Complications Associated With Cushing Syndrome?

Untreated or prolonged Cushing syndrome can affect several organs and may lead to serious complications.

Potential complications associated with Cushing syndrome include:

• High blood pressure: Excess cortisol can contribute to persistent hypertension.

• Diabetes: Cortisol can increase blood glucose and contribute to insulin resistance.

• Bone density loss: Cushing syndrome can reduce bone strength and increase the risk of osteoporosis and fractures.

• Muscle weakness: Cortisol excess can cause significant weakness, particularly in the muscles of the hips and shoulders.

• Blood clots: Cushing syndrome can increase the risk of venous thromboembolism, including clots in the legs and lungs.

• Cardiovascular disease: Long-term cortisol excess can increase cardiovascular risk.

• Infections: Cortisol can suppress immune responses and increase susceptibility to infections.

• Mental health changes: Depression, anxiety, mood changes, and problems with concentration may occur.

• Reproductive problems: Women may experience irregular or absent periods and reduced fertility, while men may develop reduced sexual interest or erectile dysfunction.

Untreated Cushing syndrome can become serious and, in some cases, life-threatening. Early diagnosis and treatment are therefore important.

When Should I See a Healthcare Provider?

A healthcare evaluation is advisable for Cushing syndrome when several characteristic symptoms develop together, particularly when they are progressive or unusual for the person's age.

Medical assessment may be appropriate when a person develops:

• Unexplained weight gain, particularly around the abdomen

• Relatively thin arms and legs despite weight gain

• Wide purple stretch marks

• Easy bruising

• Persistent muscle weakness

• Difficult-to-control high blood pressure

• Increased blood glucose without an obvious explanation

• Irregular or absent menstrual periods

• Unexplained osteoporosis or fractures at a young age

• Excessive hair growth in women

• Weight gain combined with slowed height growth in a child

• Symptoms of cortisol excess while taking long-term corticosteroids

How is Cushing Syndrome Diagnosed?

Diagnosing Cushing syndrome requires clinical assessment and biochemical testing. Because symptoms such as weight gain, high blood pressure, diabetes and fatigue are common in other conditions, symptoms alone cannot confirm the diagnosis.

The standard clinical and laboratory steps to diagnose Cushing syndrome include:

Diagnostic Summary Table

No single test is perfect. The Endocrine Society recommends appropriate biochemical testing followed by further evaluation when results are abnormal or clinical suspicion remains high.

How is Cushing Syndrome Treated and Managed?

Treatment for Cushing syndrome aims to reduce excessive cortisol exposure and address the underlying cause. The appropriate treatment depends on whether Cushing syndrome is caused by corticosteroid medicines, a pituitary tumour, an adrenal tumour or an ectopic ACTH-producing tumour causes Cushing syndrome.

The common treatments recommended for Cushing syndrome are:

Common Medicines Used to Treat Cushing Syndrome

Medicines used for Cushing syndrome are recommended according to the underlying cause, severity, treatment history and other health conditions.

Commonly recommended medicines used for Cushing syndrome may include:

• Ketoconazole: Can reduce cortisol production by inhibiting enzymes involved in steroid hormone synthesis. Liver function may need monitoring during treatment.

• Metyrapone: Reduces cortisol production and may be used when relatively rapid control of cortisol is required.

• Osilodrostat: Inhibits enzymes involved in cortisol synthesis and may be used in selected people with persistent or recurrent Cushing disease.

• Pasireotide: Acts on somatostatin receptors and can reduce ACTH secretion in some people with Cushing's disease.

• Mifepristone: Blocks the effects of cortisol at its receptor and may be considered in selected people with Cushing syndrome and type 2 diabetes or glucose intolerance and cannot undergo surgery.

• Mitotane: Used specifically for adrenal carcinomas causing Cushing syndrome.

Medication choice should be made by an endocrinologist or another appropriately qualified healthcare professional. Treatment requires monitoring because medicines that reduce or block cortisol can cause cortisol levels to become too low.

Living With Cushing Syndrome: Daily Challenges and Caregiving

Living with Cushing syndrome can be challenging because prolonged cortisol excess may affect physical strength, appearance, mood, mobility and daily functioning. Some common challenges and caregiving needs associated with Cushing syndrome are:

What is the Prognosis for Cushing Syndrome?

The prognosis depends on the underlying cause, severity of cortisol excess, complications and response to treatment.

Cushing syndrome can often be treated successfully when the underlying cause is identified and managed. However, recovery can take time, particularly when cortisol excess has caused complications involving the bones, muscles, cardiovascular system or mental health.

Some complications may improve after cortisol levels return to normal, while others may require continued treatment. For example, hypertension, diabetes, osteoporosis and psychiatric symptoms may persist for some time and require ongoing management. However, untreated or poorly managed Cushing syndrome carries a high mortality rate due to cardiovascular complications and severe infections.

Recurrence is possible, particularly in people with Cushing disease or other tumour-related causes. Long-term follow-up is therefore important after treatment.

How Can I Prevent Cushing Syndrome?

Not all forms of Cushing syndrome can be prevented. Tumour-related Cushing syndrome generally cannot be prevented because there is no established method for preventing the development of the underlying tumour.

Medication-related Cushing syndrome can often be prevented by using the lowest necessary corticosteroids and under medical supervision.

The following measures can help reduce avoidable corticosteroid-related risk:

• Take corticosteroids only as prescribed.

• Do not increase the dose without medical advice.

• Do not stop long-term corticosteroids suddenly.

• Tell the healthcare provider about all corticosteroid tablets, injections, inhalers, creams or other preparations being used.

• Attend recommended follow-up appointments when long-term corticosteroid treatment is required.

• Report unusual weight gain, easy bruising, muscle weakness or persistent high blood pressure to a healthcare professional.

The aim is not to avoid medically necessary corticosteroids, but to use the lowest effective dose for the appropriate duration under medical supervision.

Cushing Syndrome Treatment Cost in India

The cost of Cushing syndrome treatment in India varies significantly depending on the underlying cause, diagnostic tests, medicines, hospital, city and whether surgery or other specialised treatment is required.

Indicative costs for Cushing syndrome treatment are as follows:

Note: These figures are indicative rather than fixed national rates. Actual charges can vary considerably between hospitals, diagnostic centres and cities.

The total cost can be substantially higher when a patient requires surgery, prolonged hospitalisation, radiation therapy, multiple diagnostic investigations or long-term medicines. Treatment costs should therefore be confirmed directly with the hospital or diagnostic provider before planning treatment.

Does Health Insurance Cover Cushing Syndrome in India?

Yes. Health insurance plans usually cover surgical costs for Cushing syndrome treatment. It provides coverage for eligible hospitalisation for pituitary or adrenal surgery and associated diagnoses. Medicines used to reduce cortisol levels are covered under medical insurance with OPD cover. If Cushing syndrome is related to a pre-existing condition or long-term corticosteroid treatment, the policy's pre-existing disease provisions may become particularly relevant.

Treatment for Cushing syndrome including a benign brain or pituitary tumour is also covered under critical illness insurance plans. If the underlying cause is adrenal cancer, then a cancer insurance plan can also be purchased. However, always check the policy wording to check the waiting period and the coverage.

How Much Health Insurance Coverage Is Needed for Cushing Syndrome Treatment?

There is no single health insurance amount that is suitable for every person with Cushing syndrome.

The required sum insured depends on factors such as the expected treatment, hospital costs, whether surgery may be required, existing medical conditions, location and the policy's coverage limits.

For a person without an existing diagnosis who is planning health insurance for general future medical needs, a higher sum insured can provide greater financial protection against hospitalisation and major procedures. For someone already diagnosed with Cushing syndrome, the availability of coverage may also depend on pre-existing disease provisions and applicable waiting periods.

A ₹5 lakh sum insured may provide limited protection for eligible hospitalisation in some situations, but it may not be sufficient for complex endocrine surgery and prolonged treatment. A coverage of ₹10 lakh-₹20 lakh provides a wider financial cushion, while people seeking broader protection may consider higher coverage based on their circumstances and affordability.