Is it AI or just electrolytes? Or thyroid? Or an infection?

Well, durn-it-all, I had to take an extra 5 mg of hydrocortisone again tonight. That's twice this week, and actually three times if I count last Sunday when I was flying across the country coming home. I'm trying so hard to wean off of the hydro but my body just won't let me. I don't know if it's because my pituitary still isn't making enough ACTH after my surgery 18 months ago or if it's cantankerous sometimes. Or is it my adrenal glands? Have they given up the ghost?

Between the nausea, being freezing cold in a 76 degree room, the fatigue, and the headache that comes with it, there was no way around my need for the drug I both love and hate. I fought for years to get rid of the bugger that was causing my body to be overrun with the steroid only now to be dependent on it. But I never want a repeat of a couple of episodes I've had with AI. No way, no how.

So, are my electrolytes off, or do I need more cortisol? And if I do, why? Do I have an infection? That's usually my first indication of an infection, but that's not the only reason I get AI. In fact, I'm still fighting that sinus infection and see my ENT on Wednesday. The last few times other than with sinuses, it's been UTI's. I didn't even know I had them until they got so bad and became Pyelonephritis. You know, it's all relevant and we "Cushies" tend to ignore signs others don't just because we've tolerated so much for so long. It's hard to know when one is sick outside of the endocrine disease itself.

I know, I know...time to go get some blood work done. I've been putting it off for too long. I spent the week with my daughters this past week, so really need to get on the ball and go. But, I can't go in the morning. Since I have to have the serum cortisol and ACTH done at 8 a.m. and I'm supposed to withhold my hydrocortisone for 24 hours prior...well....I blew that.

I know that my pituitary has quit making a lot of things, but the tumor did that. Surely it will make ACTH again. I hope it will, but yet, I'm afraid it will, too. The chance of a recurrence within 5 years is high, and since my tumor went into my cavernous sinus and had to be scraped off the wall there, just one cell can cause it to regrow. Most of the time I don't think about that, but every now and again....like tonight....I do.

Why would my pituitary start making ACTH and not the GH or TSH I need? Oh, I've read all the research and supposition that goes with a pituitary tumor and the hormones it affects. But think about it. The pituitary has a posterior and anterior section. It also leads into the hypothalamus. The anterior section is responsible for the majority of the hormones, and those are the hormones I'm missing. All of them. TSH, GH, FSH, LH, etc. So, why would I not produce them but still produce ACTH? Yeah, you see why I'd worry if I did produce enough ACTH? Why won't I produce all the other ones?

Oh, I know, as we get older there are a lot of other things that happen in our bodies that cause the GH and estrogen to fall. And I know there are feedback mechanisms that fail, too. In fact, the hypothalamus directs a lot of the action with the anterior pituitary, including GH production.

The hypothalamus is a very small portion of the brain, but wow, is it ever busy! I'll have to do a piece on it sometime. In fact, there is some new research involving the hypothalamus and obesity. It's very interesting. If the hypothalums is damaged, a lot of the hormone production of the body goes haywire or stops. You can read more about it in Testing 101: An introduction. So, is my hypothalamus damaged? Ok, y'all....I know some of you are saying "she's dain bramaged for sure!" ;) Yeah, yeah.... I'm just curious!

So, I'm still cold, my nausea has abated to a tolerable level, and my headache is tolerable, too. Maybe I can sleep again. At least my polar fleece blanket will feel good tonight!

When cortisol is a night owl....

....or all about diurnal rhythm.

What ARE you talking about, Robin? I can hear it now. Yes, we hear a lot about cortisol and how lowering it by lowering stress can affect our weight. I'm sure you've seen the ads for the cortisol-slimming drugs/herbs, too. And we are talking about the same hormone. What is cortisol, anyway?

Cortisol is a corticosteroid hormone produced by the adrenal cortex, the outer layer of the adrenal glands which are essentially lying on top of the kidneys. Without it we die. It is the hormone that responds to "stress", both good and bad. It affects levels of multiple other hormones and electrolytes, which is another topic for another day. However, the short of it is, it is very important in the homeostasis of the body.

When the body is functioning normally, cortisol is regulated by the pituitary in a negative feedback loop with ACTH (adrenocorticotropic hormone). Basically, the pituitary produces ACTH when the body's cortisol level is low, which stimulates the adrenals to produce cortisol. ACTH is pulsatile, which means it is produced in spurts instead of evenly or consistently.

What does all this have to do with cortisol being a night owl?

In a "normal" person, cortisol is the highest around 8 a.m. and decreases to about half that value around 4 p.m. By midnight (give or take an hour each way), cortisol should be about zero or close to it with blood and salivary levels. This is a normal diurnal variation. It is also called the circadian rhythm.

When one has Cushing's, this circadian rhythm is lost, and the normal diurnal variation changes. Cushing's patients have "flat" diurnal levels of cortisol, or even higher levels at night instead of in the morning.Endotext.com explains it really well. Their diagram shows the difference between normal serum cortisol levels and the levels for those who have Cushing's. (Click on the link or the picture to see it better.)

Where does that take us? Well, to testing. Because of this change from normal to warped diurnal rhythm (or lack of), testing cortisol levels can be very useful when diagnosing Cushing's Syndrome/Disease.

The article, "Cushing's Syndrome" by John Newell-Price, Xavier Bertagna, Ashley B Grossman, Lynnette K Nieman, Lancet 2006; 367: 1605–17,Division of Clinical Sciences, University of Sheffi eld, Northern General Hospital, Sheffi eld, UK (J Newell-Price FRCP); says:

Midnight plasma cortisol or late-night salivary cortisol: Normal circadian rhythm of cortisol secretion is lost in patients with Cushing’s syndrome. A single sleeping midnight plasma cortisol concentration of less than 50 nmol/L effectively excludes Cushing’s syndrome at the time of the test and this might be especially helpful in patients in whom there has been incomplete suppression on dexamethasone testing. Concentrations of more than 50 nmol/L are noted in individuals with Cushing’s syndrome, even those who suppress serum cortisol on low-dose dexamethasone testing,96 but this cutoff lacks specificity because patients with acute illness also have values above this concentration. An awake midnight concentration of cortisol in plasma of more than 207 nmol/L diff erentiates between Cushing’s syndrome and other causes of hypercortisolaemia but can miss mild disease diagnosis in about 7% of cases. (The conversion factor of ug/dL x 27.6 = nmol/L)

So, being a night owl doesn't make you "Cushie", but if you are Cushie, you probably are a night owl. Of course, that brings us to yet another topic for another day....cyclical/intermittent/episodic Cushing's.

Cortisol whoooooooooooooooooooooooooooo.........???