Creator: Dr. Hariharan V
Published: 2015-12-25T07:04:28-04:00

Patient's Query

Hi doctor,

I am suffering with hypothyroidism and polycystic ovaries. Over last three years, I have gained 15 kg of weight. I am taking T4 150 mg, Glucophage 850 mg and Yasmin. I think I have Cushing's syndrome. My cortisol level in blood is 34 in the morning but in 24 hour urine test it is in normal level. Also my ACTH is 63.4 whereas the upper limit is 64. I am eating healthy diet and I exercise every day. Over three years now, but I cannot find a solution for this problem. I visited an endocrinologist and also a dietitian but of no use. I also have acne. If I do not take birth control pills then I will not get my periods. I am very tired all day and I even feel very difficult to move. I have anxiety too. Please help.

Answer

Dr. Hariharan V

Diabetology General Medicine Internal Medicine Nutritionist

Hi,

Welcome to icliniq.com.

There may be three possibilities. Either your polycystic ovarian syndrome and hypothyroidism are two separate disorders or it may be a pituitary or autoimmune disease which affects many organs.

When did you last check your thyroid levels? If it is too low, then you will have disturbed periods.

Pituitary is the master endocrine gland which controls all other glands. Please do the following tests, which will show whether there is any problem with pituitary, TRH (thyrotropin-releasing hormone), GnRH (gonadotropin-releasing hormone) and repeat ACTH (adrenocorticotropic hormone).

If any problem in the above tests then pituitary is affected and the treatment differs.

Also get c-ANCA (cytoplasmic anti-neutrophil cytoplasmic antibody), p-ANCA (perinuclear anti-neutrophil cytoplasmic antibody) and ANA (anti-nuclear antibody) tests to rule out autoimmune disease.

If any abnormalities seen in these tests, then you may have an autoimmune disease, which can be controlled by drugs.

Revert back with the test reports to an internal medicine physician online --> https://www.icliniq.com/ask-a-doctor-online/internal-medicine-physician

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Patient's Query

Hi doctor,

In my MRI brain and pituitary, nothing was found abnormal. I also had my kidney ultrasound which looks normal. I did blood tests for autoimmune disease and they were negative. My recent prolactin level was 28, which is above the limit. What else should I do?

Answer

Dr. Hariharan V

Diabetology General Medicine Internal Medicine Nutritionist

Hi,

Welcome back to icliniq.com.

Even if MRI brain and pituitary are normal, we cannot rule out pituitary disease. Minor problems in pituitary are not seen by MRI.

My advice is to do the above tests to rule out pituitary diseases which can cause variation in prolactin level. Since your reports for autoimmune disorders are negative, We can relax in that area.

Since you are using birth control pills for a long time, it can also cause severe weight gain and Cushing's syndrome like symptoms.

Please do the above tests and also consult your gynecologist regarding side effects of oral birth control pills.

Revert back with the blood report to an internal medicine physician online --> https://www.icliniq.com/ask-a-doctor-online/internal-medicine-physician

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Patient's Query

Hi doctor,

I got some tests done. My MRI, nerves and adrenal are normal. I did cortisol test after tablet Dexamethasone 1 mg. The value went from 34 mg/dL in the morning to 3.4 mg/L and ACTH from 63.4 pg/mL to 5.7 pg/mL. Other values are FT4 1.98 ng/dL, GH 4.4 ng/mL, SM-C 104 ng/mL, anti-TPO 9 IU/mL, anti-TG 40 IU/mL and creatinine 0.60 mg/dL. GnRH and TRH are yet to be done. From the results, what is your opinion about my condition? Is it Cushing's syndrome? Should I take Signifor or Metyrapone?

Answer

Dr. Hariharan V

Diabetology General Medicine Internal Medicine Nutritionist

Hi,

Welcome back to icliniq.com.

I went through the reports (attachment removed to protect patient identity) posted by you.

Your reports are fine and definitely you do not have Cushing's. Moreover, your BMI (body mass Index) is 25 which is quite normal (high normal). So, I do not think you have any disease that is causing you unusual weight gain.

Hypothyroidism can cause weight gain but in your case your free T4 is slightly on the higher side. It would have been more informative if you had uploaded TSH report.

The other possibility is the birth control pills that you take even Yasmin can cause weight gain.

From your side what you need to do is keep your thyroid levels under control. Kindly upload me your recent TSH so that I can adjust your medication dose. Ask your gynecologist, an alternative medication for your periods problem.

Continue exercising and make slight increments in the time or intensity of exercise.

Otherwise, you do not have any endocrinological problem. One more advise is to get tested for diabetes.

Revert back with TSH report to an internal medicine physician online --> https://www.icliniq.com/ask-a-doctor-online/internal-medicine-physician

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Patient's Query

Hi doctor,

My main problem is that I am keep gaining weight. I was 55 kg and now I am 75 kg. I put on 8 kg in a month when the doctor changed the T4 dose from 75 mg to 50 mg. Gained 5 kg in two weeks when the doctor changed T4 from 150 mg to 100 mg. I exercise every day and my diet includes healthy foods such as salads, fruits, vegetables, turkey and chicken. Definitely there is something wrong. Should I control cortisol levels with pills? My TSH level is 1.98.

Answer

Dr. Hariharan V

Diabetology General Medicine Internal Medicine Nutritionist

Hi,

Welcome back to icliniq.com.

Your TSH is in normal range. So, the decision to reduce your thyroid medication dose is right.

Coming to your cortisol levels, normal morning levels of cortisol is 7 - 28 ug/dL. In your case it is 34, which is a mild elevation. This mild elevation can be explained by your consumption of Yasmin tablet.

My recommendation is to stop taking Yasmin for two months and monitor your weight. Also repeat serum cortisol after two months.

I strongly feel after stopping Yasmin with continued exercise and diet, you shall start losing weight.

For further information consult an internal medicine physician online --> https://www.icliniq.com/ask-a-doctor-online/internal-medicine-physician

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Patient's Query

Hi doctor,

Even I have tried this before. I have stopped Yasmin twice for 6 months and nothing happened. I cannot lose weight and I cannot reduce T4 dose because I will gain even more weight. My morning cortisol is 34 and prolactin is 28. Should I use Metyrapone or something else to control cortisol and to lose weight? Nothing happened with exercise and healthy meals for about three years and three months now. I have consulted many doctors and I have done many tests but there is no solution to my problem. Can you please help me? Any ideas or suggestions of what I may have. My diabetes test in also negative.

Answer

Dr. Hariharan V

Diabetology General Medicine Internal Medicine Nutritionist

Hi,

Welcome back to icliniq.com.

There are two issues here. Weight gain and high cortisol.

High cortisol and weight gain could be due to Yasmin intake. As you are saying that weight gain is happening even after stopping Yasmin for six months, we need to consider other causes of weight gain.

What I need to know is whether your cortisol was tested while you were on yasmin or not. If it was done while you were on Yasmin then I recommend you to repeat the cortisol levels after two months of stopping Yasmin. Or get a test called free cortisol which is not affected by Yasmin intake.

If the cortisol test was already done while not on Yasmin then I recommend further test. Since your ACTH is normal we need to evaluate adrenal cause of elevated cortisol. In that regard, I recommend CT scan of adrenal gland and revert back with report.

Do not be in urgency to get started on medication to bring down cortisol. We should first know what is the cause of elevated cortisol as certain tumors can also cause elevated cortisol.

Revert back with the scan report to an internal medicine physician online --> https://www.icliniq.com/ask-a-doctor-online/internal-medicine-physician

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Patient's Query

Hi doctor,

My MRI nerves, adrenal, brain and pituitary were normal. Also my kidneys are normal in ultrasound. I have done free cortisol test in urine for 24 hours one month back with the same tablet and it was 60 mg/24 hours, hv = 1230 mL and cortisol in blood was 21.04 mg/dL. The problem is not only increasing weight, I also have anxiety and headache every day. Periods problem and acne trouble too. I feel tired the whole day.

Answer

Dr. Hariharan V

Diabetology General Medicine Internal Medicine Nutritionist

Hi,

Welcome back to icliniq.com.

The normal range for urinary free cortisol is 3.5 - 45 ug/24 hour while you have 60. This could be taken as suggestive of Cushing's but a normal Dexamethasone suppression test goes against Cushing's. So, there is a dilemma here.

That too a normal MRI brain, pituitary and adrenal scans supports the diagnosis as not Cushing's.

There are two options for you. One wait for 6-8 weeks and get the tests re-done that is urinary free cortisol and Dexamethasone suppression test or get started on treatment with Ketoconazole or Metyrapone.

One thing you need to understand is if started on treatment with Ketoconazole or Metyrapone may cause reduced efficacy of Yasmin. Among the two option I recommend the first one.

Revert back with the investigation report to an internal medicine physician online --> https://www.icliniq.com/ask-a-doctor-online/internal-medicine-physician

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Patient's Query

Hi doctor,

I have read that only 50% of pituitary tumors only seen in MRI. I have reduced the efficacy of Yasmin. My periods is irregular now. With these pills, will I lose weight, anxiety, headaches and tiredness?

Answer

Dr. Hariharan V

Diabetology General Medicine Internal Medicine Nutritionist

Hi,

Welcome back to icliniq.com.

Yes, not all tumors will be seen in MRI. But, next time when you go for scan ask for pituitary scan and not just MRI brain. Also get it in a MRI of 3 Tesla strength.

After the start of medication, your weight gain will slow down. But I do not think you will loss weight.

For weight loss you need to continue diet and exercise.

Your headache, anxiety and feeling of tiredness will reduce.

You may have irregular periods due to reduced effectiveness of Yasmin.

For further information consult an internal medicine physician online --> https://www.icliniq.com/ask-a-doctor-online/internal-medicine-physician

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Patient's Query

Hi doctor,

I have done three separate MRIs for brain, pituitary and adrenal gland. Well, If I continue exercising and eat healthy along with prescribed medicine, will I lose weight?

Answer

Dr. Hariharan V

Diabetology General Medicine Internal Medicine Nutritionist

Hi,

Welcome back to icliniq.com.

Yes, you will lose weight. Please follow my advice for better outcome.

You should avoid non-vegetarian food including chicken. Eat more of fruits and vegetables.

Whatever exercise you do, make sure that you increase the intensity or duration or both every two weeks.

You can try herbal supplements like Garcinia which improves metabolism and helps in weight loss.

Ask an alternative for Yasmin with your gynecologist.

For further information consult an internal medicine physician online --> https://www.icliniq.com/ask-a-doctor-online/internal-medicine-physician

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Patient's Query

Hi doctor,

I read that Metyrapone is 75% effective and Mifepristone 60%. What dosage do you suggest for me? Regarding an alternative of Yasmin, should I go for anything seasonale?

Answer

Dr. Hariharan V

Diabetology General Medicine Internal Medicine Nutritionist

Hi,

Welcome back to icliniq.com.

Mifepristone is not approved for long term treatment, hence I recommend you go ahead with Metyrapone only.

Regarding alternative for Yasmin you need to discuss it with your gynecologist, ask for non-steroidal medicine seasonale also will not help.

Yes, I do suggest you to avoid meat, fish and egg white is fine but chicken and mutton has to be stopped.

For further information consult an internal medicine physician online --> https://www.icliniq.com/ask-a-doctor-online/internal-medicine-physician

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Patient's Query

Hi doctor,

I had few tests yesterday. My 24 hour cortisol in urine is 72.1 mcg/g CR; previously it was 60 mcg/g CR. Early morning cortisol is 40.5 mg/dL while previous one was 38 mg/dL. ACTH is 80.8 pg/ml and last one was 63.4 pg/mL. After this I had high dose suppression test with Dexamethasone 8 mg and here are the results. Cortisol 2.5 mg/dL and ACTH 1.9 pg/mL. I read that if the disease is Cushing, suppression will be more than 60%. What does it mean?

Answer

Dr. Hariharan V

Diabetology General Medicine Internal Medicine Nutritionist

Hi,

Welcome to icliniq.com.

Dexamethasone suppression test is done to differentiate between Cushing's syndrome and Cushing disease.

Suppression is seen either in normal individuals or in Cushing disease. So, this indicates that you have Cushing disease.

The basic requirement for this test is women who are taking oral contraceptive pills (Yasmin in your case) should discontinue the drug for at least six weeks prior to the test.

If you have done the test while on Yasmin, then this test does not hold any significance.

For further information consult an internal medicine physician online --> https://www.icliniq.com/ask-a-doctor-online/internal-medicine-physician

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