Theodore C. Friedman, M.D., Ph.D. has opened a private practice, specializing in treating patients with adrenal, pituitary, thyroid and fatigue disorders. Dr. Friedman has privileges at Cedars-Sinai Medical Center and Martin Luther King Medical Center. His practice includes detecting and treating hormone imbalances, including hormone replacement therapy. Dr. Friedman is also an expert in diagnosing and treating pituitary disorders, including Cushings disease and syndrome.

Dr. Friedman's 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, including the University of Michigan, the National Institutes of Health, Cedars-Sinai Medical Center, and UCLA's Charles Drew University of Medicine and Science.

Read Dr. Friedman's First Guest Chat, November 11, 2003

Listen to Dr. Friedman First Live Voice Interview, January 29, 2009 
Listen to Dr. Friedman Second Live Voice Interview, March 12, 2009 
Listen to Dr. Friedman Third Live Voice Interview, February 13, 2011
Listen to Dr. Friedman Fourth Live Voice Interview, March 12, 2012

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

This is Dr Friedman's second guest chat March 2, 2004.

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. Dr. Friedman's website is goodhormonehealth.com.

Please remember, everyone, that Dr. Friedman cannot diagnose or treat someone without seeing them. It's not intended as a substitute for a good endocrinologist with expertise in Cushing's.

Welcome back to Cushing's Help and Support, Dr. Friedman! Dr. Friedman, do you have anything you'd like to say before we start?

Theodore Friedman, M.D., Ph.D.: Hi everyone! I hope this is informative. I can't answer specific questions, but would be happy to see you in my clinic.

Kristin: I am a year post op pituitary surgery and lost 40% of my pituitary and still have severe dizziness and headaches and fatigue.

MaryO: I'm sure we'd all like to see you, too!

Theodore Friedman, M.D., Ph.D.: You may have growth hormone deficiency. you should also make sure your thyroid, testosterone, DHEAS and estrogen levels are ok. GH deficiency is the most common reason for fatigue, post op.

Maggie2: Hi Dr. Friedman, I am 54, an MRI shows a pituitary adenoma, ACTH levels are 123 ng/L normal is 9 - 52. An AM plasma cortisol was 685 (normal 120 - 620) A 24 hr. urine was 143, normal is less than 300. A midnight salivary cortisol was 2.9 normal is less than 3.6. A.M. testosterone was 2.5, normal is 0.6 to 2.0. P.M. DHEA was 8.6. Normal is 1.0-7.0.

My symptoms are weight gain, moon face, buffalo hump, ruddy face, muscle weakness, fatigue, facial hair, memory loss, cognition problems, low libido, and others. I've been told by an endo I probably don't have Cushing's.

My question: Does this sound like Cushing's and should I continue to pursue a diagnosis of Cushing's? Should I be checked for adult growth hormone deficiency?

Theodore Friedman, M.D., Ph.D.: Maggie, I would continue the Cushing's workup as you may be periodic and also be checked for GH deficiency.

Ikho1967: Hi Doc. Your Boston Patient Lisa E. here. I know my GH stim test is ok, but why would IFG1 go from low normal 156 to 118 in one month? Since IGF1 is insulin marker should I be checked for diabetes?

Theodore Friedman, M.D., Ph.D.: No, IGF1 is not an insulin marker, high cortisol can suppress IGF1, so perhaps your cortisol was higher the 2nd time, or maybe different labs.

DaraRocks: Hi, Dr. Friedman, thanks for spending time with us tonight! I have had 3 UFCs that have had normal cortisol but elevated 17-OHCS. My GP believes these results to mean I am in the early stages of Cushing's but the endocrinologists disagree. I have had a lot of Cushing's symptoms including an 80 pound weight gain over 5-6 months. What would you suggest my next step should be?

Theodore Friedman, M.D., Ph.D.: I'm finding that elevated 17-OHS are found in early Cushing's, I would do other Cushing's test like nighttime salivary cortisol or dex/crh.

DaraRocks: I have had a 1mg overnight dex test and suppressed. Is that reliable?

Theodore Friedman, M.D., Ph.D.: Probably not, I'm finding most mild Cushing's suppress to 1 mg dex.

Trish: I had a hysterectomy in Nov. 03. My cortisol was very high in Jan. 04 as well as my progesterone? What would elevate progesterone post-hysterectomy without supplementation?

Theodore Friedman, M.D., Ph.D.: Oral estrogens. If you are not on them, you could have Cushing's.

Trish: Did not take oral estrogen, just the Estraderm patch.

Theodore Friedman, M.D., Ph.D.: What time of the day? Morning cortisols are not particularly helpful.

Teresa: If a person has an ACTH blood level over 300 post BLA (bilateral adrenalectomy) does that mean that the original source of the Cushing's was pituitary, or is there still a possibility that it could be ectopic?

Theodore Friedman, M.D., Ph.D.: It could be pituitary or ectopic.

Teresa: Darn, thanks.

Theodore Friedman, M.D., Ph.D.: Following adrenalectomy an ACTH level of 300 is appropriate.

Nona: My doctor prescribed Avandia last spring to control Type II diabetes, and some of my Cushing's symptoms improved. 24-hr and blood test came back in normal range while taking Avandia. Now that I am off Avandia I have throbbing pulse, sweating, thirst, excessive urination, headaches, and an unbelievable jitteriness. Is this indicative of a cortisol "high"? How long do I have to be off Avandia before resuming testing for Cushing's?

Theodore Friedman, M.D., Ph.D.: Avandia in some patients suppresses ACTH, so off Avandia you could have your Cushing's more apparent, I would recheck in 2 months.

MC: Dr. Friedman, thank you for your time. I will be 2 years post-op (May) from pituitary surgery (3rd one in all). I am hypopit (hypopituitary) and on replacement sex hormones, Synthroid, Cortef. How much of GH deficiency symptoms can be replaced by upping other hormones i.e. estrogen and thyroid medications?

Theodore Friedman, M.D., Ph.D.: Not at all, if you are GH deficient you need GH. Higher thyroid may lower your GH.

Missy: Is it possible to have cortisol hyperfunctioning adenomas bilaterally.

Theodore Friedman, M.D., Ph.D.: Pituitary or ectopic Cushing's gives bilateral hyperfunctioning adenomas.

BullTerrier: I have bilateral adrenal hyperplasia, on CT Left adrenal enlarged, R normal, Iodocholesterol scan 65% uptake L, 35% R, having a L adrenalectomy 11 March, what is the success rate with unilateral? I am giving it a try first, I know bilateral adrenalectomy is preferred method of treatment. Not much literature on this type of Cushing's. Just curious.

Theodore Friedman, M.D., Ph.D.: What is your ACTH?

BullTerrier: Very low.

Theodore Friedman, M.D., Ph.D.: Then a unilateral should do it.

BullTerrier: Thank you, have my fingers crossed.

Christy: Can pregnancy cause Cushing's symptoms?

Theodore Friedman, M.D., Ph.D.: Yes, cortisol is high in pregnancy or you could get Cushing's while pregnant.

Magician: I have a posterior pituitary tumor. 24 hour urine of 269 nmol and morning serum cortisol of 987. Neck hump, etc. I'm in Canada. Would I be diagnosed with Cushing's if I was in the US? Thank you for your time.

Theodore Friedman, M.D., Ph.D.: Can you convert those to U.S. units of ug/d and ug /dl?

Magician: I don't know the conversion, I'm sorry.

Theodore Friedman, M.D., Ph.D.: Morning cortisol is not helpful. I would do a bunch of UFC/17-OHS and nighttime salivary cortisol.

KathiK: This is Kathi Kalpakoff. After my MRI (scheduled for 3/8) can we test for GH deficiency? I'm getting dizzy before my periods too. This is scary. Had these dizzy spells 4 years ago too before I knew I had Cushing's. Could GH deficiency cause these spells or just Cushing's?

Theodore Friedman, M.D., Ph.D.: It could be low cortisol. I'm also finding low aldosterone in some hypopit patients. We can test you for that.

Kristin: Is it normal to still be suffering from severe headaches and dizziness when I am 13 months post pituitary surgery (I did have 40% removed), and I still have no cortisol.

Theodore Friedman, M.D., Ph.D.: Headaches and dizziness make me think your cortisol is low, but I'm surprised it would be low, so long post op.

Kristin: I am on 30 mg, I was on 20. I am very tiny.

Theodore Friedman, M.D., Ph.D.: Did you feel better on 30?

Kristin: No, the same. Sometimes I feel bad on 20 and sometimes good.

Theodore Friedman, M.D., Ph.D.: Then I would check other hormones and try to get off, maybe check renin and aldosterone.

Kristin: I was really fatigued and tired so I moved up to 30 for that reason only. what is renin?

Theodore Friedman, M.D., Ph.D.: It's a hormone made by the kidneys that regulates aldosterone, which regulates salt.

Kristin: Try to get off what? the extra hydrocortisone?

Theodore Friedman, M.D., Ph.D.: Yes, try to get off cortisone.

MaryO: Dr. Friedman, do you want to give contact info, in case anyone would like to come see you?

Theodore Friedman, M.D., Ph.D.: Sure! My website is goodhormonehealth.com.

Lag: With cyclical Cushing's, would you always have a high period? A doctor thinks I might have it, but I'm either tired or really really tired, but never very up. But other tests are a good match for cyclical Cushing's, and an MRI is scheduled. Can you have it without a recognizable "high"?

Theodore Friedman, M.D., Ph.D.: If there is no high,then you shouldn't have signs or symptoms of Cushing's.

SWelshAntiques: Hi Dr. F. Sharan (aka Meghan's Mom) here. Any thoughts on what would cause a patient who is suspected of having Cushing's and is on 2000 mg a day of Metformin to have blood sugar levels (using glucometer) in the 170 to 190 range? This is with restricting intake of sugar and carbs. Would you consider this abnormal? Thank you.

Theodore Friedman, M.D., Ph.D.: No, diabetes is common in Cushing's.

DaraRocks: Doctor I had a decreased DHEAs level on my 1 mg overnight dex test, could the dex have lowered my DHEAs?

Theodore Friedman, M.D., Ph.D.: Yes, dex should suppress DHEAS.

Lorrie: What is the minimum hydrocortisone maintenance dose for a BLA patient?

Theodore Friedman, M.D., Ph.D.: With proper Florinef replacement, you can get by on 15-20 mg/day.

Lorrie: Is it possible to get by on 10mg or less?

Theodore Friedman, M.D., Ph.D.: 10 is pretty little, but if you do ok on it, then its fine.

MaryO: Dr Friedman, why do you think that you're so good at diagnosing Cushing's when other doctors miss the diagnosis?

Theodore Friedman, M.D., Ph.D.: I've been trained by a lot of Cushing's experts and have seen a lot of patients with it.

Maggie2: Can the symptoms of Adult Growth Hormone Deficiency cycle in a similar fashion to cyclic Cushing's or do the symptoms remain constant through the weeks and months?

Theodore Friedman, M.D., Ph.D.: More constant. I think Cushing's and GH deficiency can have similar symptoms, with GH not effecting the skin.

Ikho1967: What is the Esoterix 24 UFC number you are looking for as more definitive of Cushing's? One center looks for 70, but I think uses RAI. Also does cortisol suppress aldosterone?

Theodore Friedman, M.D., Ph.D.: For women > 35 is suspicious (with proper signs and symptoms. Cortisol can suppress aldosterone, but with high cortisol, you wouldn't have the symptoms of low aldosterone.

SallyC: Strange question, but it is okay that I feel so fantastic this so quickly after my pituitary surgery on December 15th? Everyone else seems to suffer so much, and other than a few aches, I feel wonderful. Does this sometimes happen with people who are cured of Cushing's?

Theodore Friedman, M.D., Ph.D.: Good news, it can happen that you feel good.

Natalie: Hi Doc! :) Natalie, 38f, Brisbane, Australia. I used to be a 'ball of endless energy' type person, 'bouncing off the walls' of a day-time and sleeping only 4 or 5 hours max of a night-time. I'm approximately 18 months post failed pituitary surgery, and approximately 14 months post the conclusion of 6 weeks of R.T. ... and ... I'm still ttttiiiirrreeeedddd!!!!!!!!!!!!! What I'm trying to find out at the moment, is .... is this IT? ... am I going to be only ...like... half awake and in need of an afternoon nap, for the rest of my life?

Theodore Friedman, M.D., Ph.D.: It could be GH deficiency.

Natalie: It's bottom of the scale - is supplement needed?

Theodore Friedman, M.D., Ph.D.: Also patients with hypothyroidism have a low free t4 with nil TSH, so you be hypothyroid. It sounds like GH will be the key.

DaraRocks: What, besides early Cushing's, could cause an elevated 17-OHS but a normal cortisol level? And is there a formula to factor in creatinine, and why would that be necessary?

Theodore Friedman, M.D., Ph.D.: Yes, sometimes you correct for creatinine. if its high both corrected and uncorrected, I'm suspicious. Pseudo Cushing's can also give high 17-OHS.

Lorrie: What is the best testing method to assess cortisol production status post BLA?

Theodore Friedman, M.D., Ph.D.: 24 hr urine for 17-OHS can be used to monitor cortisol on Cortef. If you want to see whether you are making any on your own, check a morning cortisol after not taking Cortef for 24 hr.

Magician: How long must one be off the Pill prior to beginning Cushing's testing?

Theodore Friedman, M.D., Ph.D.: It's not proven that you need to be off the pill, but I think it makes testing easier and I would be off 2 months.

KathiK: If I could be low on cortisol then why would my abdomen swell a week or 2 before my period? It gets quite large, I look ready to deliver.

Theodore Friedman, M.D., Ph.D.: No easy answer. Sorry.

Teresa: Are ectopic sources of Cushing's always malignant or can they be caused by a benign tumor?

Theodore Friedman, M.D., Ph.D.: If caught early they can be benign. If late, often malignant.

Teresa: OK, I need to be able to stop this worry, thank you very much Dr Friedman.

Freddy: I have DHEA level of 47. I'm post pituitary op 2 years and still extremely tired, depressed, very low libido, weight gain again after losing post op. Is this related to my DHEA level? Should I have anything else checked?

Theodore Friedman, M.D., Ph.D.: It could be DHEA, but more likely low testosterone or GH.

Amber: Hello Dr. I'm concerned about the lasting effects of Depo Provera (some say it can take 18 months to be gone from your system). I was on it for a year and have been off it for 6 months. As of 4 months ago, estrogen was still quite low. Will we be ok to test in April?

Theodore Friedman, M.D., Ph.D.: Should be fine.

Maggie2: Which tests are best for diagnosing Cushing's and how often would you repeat them?

Theodore Friedman, M.D., Ph.D.: UFC 17-OHS salivary cortisol. I usually do each about 3-4 times.

TinklesInJug: What do you think is the most effective way to rule out mild and or cyclic Cushing's; like what should I suggest to my doctor. And would you have any special considerations for diagnosing Cushing's in young people?

Theodore Friedman, M.D., Ph.D.: Multiple urines for UFC, 17-OHS and nighttime salivary cortiols when feeling like high cortisol. Nothing special in kids.

Shauna: Dr. Friedman, as you know, I'm only taking my steroids every four days or so. I have no problems with feeling weak or crisis-like (bilateral adrenalectomy). Is there any explanation for this?

Theodore Friedman, M.D., Ph.D.: Possible adrenal rest tissue, I would check a morning cortisol after not taking cortisol for 24 hours.

Shauna: We've done that, no rest tissue.

Theodore Friedman, M.D., Ph.D.: Strange, maybe you are not breaking down the cortisol. Weren't you earlier on high doses of steroids.

Shauna: Yes, I was. Thank you.

MaryO: For those of us who don't know, what's adrenal rest tissue?

Theodore Friedman, M.D., Ph.D.: After bilateral adrenalectomy for Cushing's, the ACTH from the pituitary drives adrenal tissue to grow in places it shouldn't be.

Lorrie: What are the expected AM cortisol and UFC levels in a BLA patient?

Theodore Friedman, M.D., Ph.D.: Off steroids, close to zero. On steroids, I use 17-OHS to monitor and it should be in upper normal range (Shauna should do that).

Lorrie: When you say close to zero does that mean less than 1?

Theodore Friedman, M.D., Ph.D.: Yes, if the last dose of Cortef was 24 hrs ago.

Lorrie: I had a 9 one week and then a 0.9 two week later.

Ashley65: Dr. Friedman, I have an adrenal MRI scheduled for Friday. I am wondering what the likelihood is you think they will find something given a urine free cortisol of 243, serum 20.5 and ACTH 14 at 11am. I am on Spironolactone, birth control and keep gaining weight, also have thyroid peroxidase antibody so hypothyroid. When I was 13, they were sure I had Cushing's but could not find the tumor. Now it is 25 years later and suspected again.

Theodore Friedman, M.D., Ph.D.: The ACTH of 14 at 11 am makes me think pituitary rather than adrenal.

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

Remember to visit Dr. Friedman's Web site at goodhormonehealth.com. Please joining me in thanking him for answering all our questions tonight.

Theodore Friedman, M.D., Ph.D.: Thanks everyone! Good luck and GOOD HORMONE HEALTH to everyone.


 

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