April 18, 2007

In This Issue

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• Robin writes: Getting "Flakey" in a geeky way, Research, bookmarks, and general info to share


• Abnormal Uterine Bleeding May Be Best Evaluated by Menopausal Status

• Screening Of Cushing's Syndrome In Adult Patients Newly Diagnosed To Have Diabetes Mellitus


• Adrenal Gland Volume and Dexamethasone-Suppressed Cortisol Correlate with Total Daily Salivary Cortisol in African-American Women


(Acromegaly) Growing feet could mean tumour

Acromegaly Masquerading as Polycystic Ovary Syndrome

Aging: Disease or Business Opportunity?

Kickboxing Causes Damage To Hormone Producing Area In Brain

ECT in Patients With Intracranial Masses

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Pictures from the Pittsburgh, PA Christmas Dinner, December 13, 2006
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Pictures from the April 5-8, 2006 CUSH Cushing's Awareness Day Medical Forum, held in Oklahoma City, OK
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April 20, 2007, Attend a meeting of the NIH Director's Council of Public Representatives More info here.

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June 2-5, 2007, ENDO 2007, Toronto, Canada, Metro Toronto Center.

• Discussions about Minneapolis in June here

October 6, 2007, Rockford, IL. tentative. More information

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Recruiting men with pituitary disease who have testosterone and growth hormone deficiencies.  More Info

Dr. Theodore Friedman from Charles R. Drew University, Division of Endocrinology is currently seeking patients to participate in a research study of pituitary dysfunction. More info.

• The message boards now number over 6,000 participants.

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Latest Media:

Sam who has been on The Mystery Diagnosis TV Show (Discovery Health) has been invited to appear on Dr. Phil taping soon. More info as it becomes available.

Helpful Books (pituitary):
Art Russell shares the powerful story of his struggle with Cushing's Disease.

October 18, 2006 Obese from Secret Disease (ABC News) (Jaimie on the boards) Read this article »

Jun 17, 2006 Student hopes to rebound from brain surgery Rare disease caused teen to double weight in a year Read this article »

May 21, 2006 Rare disease treated at OHSU (sowens on the boards) Read this article »

May 15, 2006 Patients Fighting Cushings Disease (Rooon on the boards)
Read this article »

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A Young Woman's Battle with a Hidden Enemy: Cushing's Disease

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Doctors updated:
Dr William Ludlam after his move to Seattle, WA from Portland, OR.
Dr. Ted Friedman, book added: The Everything Health Guide to Thyroid Disease: Professional Advice on Getting the Right Diagnosis, Managing Your Symptoms, And Feeling Great (Everything: Health and Fitness)
Dr. Blevins is leaving Vanderbilt Hospital to accept a position as Medical Director of the California Center for Pituitary Disorders at UCSF in California beginning May 1, 2007.
Dr. Maria Fleseriu, Oregon Health and Science University
Dr. Roberto Salvatori, Johns Hopkins, Baltimore, MD
More info here
Dr. James Neifing, Portland, OR

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In Memory

(Alena) Renea Weeks Greenhill

Sue Ann Koziol (SuziQ),
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Sue was a very special friend to Cushies world-wide. We will remember her always.

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On the Message Boards

Robin writes: Getting "Flakey" in a geeky way, Research, bookmarks, and general info to share

I've been having a lot of fun "flaking"..... I'm exploring the new Web 2.0 technologies which include wiki's, podcasts, newsfeeds, and flakes.....

I've built a flake for Cushing's to share what info I have with anyone who wants to use it. I'm still working on it and have a lot more to add, but I'll do it as I can. A lot of things I've put there point back to this site, and if it's a link to the boards, only board members will be able to see it.


I've put a feed of my bookmarks on the flake site, but I also have another public site for them, too:


The neat thing about all this is you can do this, too, and we can "network", sharing with each other. You can incorporate my stuff in to your flake, and I can incorporate yours. It's a way for us to share info with each other. MaryO may want to put links to all this on here...I don't know. But it's the "new" thang, and predicted to be how things are going.

Updated Pages on the Website:

Testimonials http://www.cushings-help.com/testimonials.htm

Thank you, Mary! I appreciate the quick response...Your Cushings site is a god-send. I stayed up all night (literally--till 6 am) reading last night....Anyway, thank you so much for providing this valuable resource! I look forward to participating on the forums (after a long nap today...LOL).

Thank you Mary the list is fantastic. The work that you put into this site is really appreciated more than you will ever know. Saying THANK YOU one million times would not be enough to show how much this site means to me. You are a living angel Mary and deserve the very best of everything good in this world.

Thanks Mary - I must say these boards bring a smile to my face each day...you continue to surprise me with all the new features - me being a gadget person - I am in my element. Thanks a bunch you wonderful lady!!!!

I have been reading for a while now and I thank God for this website and every last one of you who make this like the family I never knew existed.

From Amy's Bio

Take the time to go through the information at this site. It includes how to get to the best resource site on the web, Mary O's Cushing's Help and Support website at http://www.cushings-help.com. She includes a lot of information in her site, and a message board for you to join and ask questions, share information, and meet others who are doing the same.

From Robin's Flake

News Items:


• Sam who has been on The Mystery Diagnosis TV Show (Discovery Health) has been invited to appear on Dr. Phil taping soon. More info as it becomes available.

Dr. Theodore Friedman from Charles R. Drew University, Division of Endocrinology is currently seeking patients to participate in a research study of pituitary dysfunction. More info.

Ages 18-55.

To Undergo Baseline Studies to Evaluate Consequences of Low Testosterone and To Receive Testosterone Replacement for 2 Months.

Subjects Will Be Compensated.


Dr. Friedman or Dr. Zuckerbraun
Charles R. Drew University - Clinical Research Center
1731 E. 120th Street
Los Angeles, CA 90059
Telephone: 323-563-9353
Email: study@goodhormonehealth.com


Provided by

Recruiting men with pituitary disease who have testosterone and growth hormone deficiencies.

Both testosterone and growth hormone individually improve bone density in men who have deficiencies of these hormones. The purpose of this research study is to determine if the combination of testosterone and growth hormone improves bone structure more than testosterone alone.

Thirteen outpatient visits over a 2-year period are required. Bone structure will be evaluated three times (at the beginning, after 12 months, and after 24 months). Three kinds of tests will be performed: DEXA, MRI and p-QCT. All three are non-invasive tests of bone quality and low risk.

By participating in this study you will learn more about the health of your bones and other aspects of your health. Reports will be provided to you and to any physician you wish. The study covers the cost of all study procedures and medications.

Study Criteria:

  • Be male and over 18 years of age
  • Have documented pituitary disease
  • Be deficient in testosterone and growth hormone
  • Have not taken growth hormone or testosterone within the past two years

elen Peachey, RN, Research Coordinator
University of Pennsylvania Health System
Department of Endocrinology
778 Clinical Research Bldg.
415 Curie Blvd.
Philadelphia, PA 19104
Telephone: 215-898-5664
Fax: 215-573-5809
Email: peacheyh@mail.med.upenn.edu


Profile Page: University of Pennsylvania Health System, Philadelphia, PA

Provided by


• From http://www.medscape.com/viewarticle/555284

Abnormal Uterine Bleeding May Be Best Evaluated by Menopausal Status  CME

News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd


Release Date: April 17, 2007Valid for credit through April 17, 2008
Credits Available
Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™ for physicians;
Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians


April 17, 2007 — The best approach to evaluating and treating abnormal uterine bleeding is to stratify women by premenopausal, perimenopausal, or postmenopausal status, according to a review published in the April issue of the Southern Medicine Journal. This review describes the differential diagnosis and diagnostic workup of abnormal uterine bleeding, defines an approach to etiology, and discusses treatment options.

"Disorders of the menstrual cycle are a common problem in ambulatory medicine, accounting for up to 30% of outpatient visits to gynecologists," write Sara B. Fazio, MD, and Amy N. Ship, MD, from the Harvard Medical School in Boston, Massachusetts. "Abnormal uterine bleeding describes bleeding that is excessive or outside the normal menstrual cycle. In the premenopausal woman, the differential diagnosis is broad, and pregnancy must always be considered."

In premenopausal women, after pregnancy has been excluded, the most important branch point is determining whether the bleeding is ovulatory or anovulatory. One of the most common causes of abnormal uterine bleeding is anovulation. In patients with anovulatory bleeding, treatment goals are to regulate cycles, minimize blood loss, and prevent iatrogenic complications from chronic unopposed estrogen treatment.

After determining the etiology of oligomenorrhea or amenorrhea, management should include maintenance of adequate estrogen to support bone health. The increasing incidence of endometrial hyperplasia and malignancy in the perimenopausal and postmenopausal population mandates a low threshold for endometrial assessment and referral to a gynecological specialist.

"Abnormal uterine bleeding is a common condition, and evaluation is best approached by stratifying into pre-, peri-, and postmenopausal status," the authors conclude. "Utilizing a systematic approach to the differential diagnosis will help to avoid a misdiagnosis. Much of the evaluation and treatment can be done in the office of the internist."

The authors have disclosed no relevant financial relationships.

South Med J. 2007;100:376-382.

Clinical Context

According to the authors of the current study, abnormal uterine bleeding accounts for up to 30% of outpatient visits to gynecologists and is described as bleeding that is excessive or outside of normal cyclic menstruation. A typical cycle interval is 21 to 35 days with an average flow duration of 2 to 8 days and estimated blood loss between 30 and 80 mL. Predictors of heavy bleeding include passage of clots, iron deficiency anemia, and volume depletion. While estrogen increases thickness and vascularity of the endometrium, progesterone increases the glandular secretions and vessel tortuosity, and withdrawal of sex steroids results in endometrial sloughing and bleeding.

This is a review of the differential diagnosis of abnormal uterine bleeding and treatment in premenopausal, perimenopausal, and postmenopausal women.

Study Highlights

  • A thorough history including sexual history and domestic violence screening is recommended.
  • Physical examination should include pelvic examination and identifying alternate sources of bleeding such as rectal or urethral.
  • For the premenopausal woman, the bleeding should be characterized as ovulatory or anovulatory.
  • In the perimenopausal and postmenopausal woman, malignancy becomes of greater concern.
  • Women with abnormal uterine bleeding should have a pregnancy test (if premenopausal), complete blood count, and a Papanicolaou test if not recently performed.
  • Cervical cultures may be indicated.
  • Ovulatory status may be determined using the basal body temperature method or serum progesterone levels.
  • If anovulatory cycles are suspected, thyroid function and prolactin level should be obtained.
  • Adolescents require a screening for hypothalamic causes and coagulopathy.
  • Luteinizing hormone/follicle-stimulating hormone and dehydroepiandrosterone sulfate levels can help in diagnosis of polycystic ovary syndrome (PCOS).
  • Premenopausal Women
    • Pregnancy must be considered and can present as amenorrhea or light spotting; early pregnancy, spontaneous abortion, and ectopic pregnancy are possibilities.
    • Anovulation can lead to episodic menstruation at short intervals and may occur in adolescence or near menopause.
    • Chronic anovulation may be caused by PCOS.
    • PCOS diagnosis is made when at least 2 of the following are present: oligomenorrhea or anovulation, clinical or laboratory evidence of androgen excess, and polycystic ovaries on ultrasound.
    • Ultrasound evidence is neither necessary nor sufficient to make a diagnosis of PCOS.
    • Anovulation also may occur in hypothalamic dysfunction (secondary to stress, systemic illness, and sudden weight loss) or with prolactinemia (caused by pituitary prolactinoma or neuroleptics).
    • Menorrhagia is reported in women with subclinical or overt hypothyroidism and Cushing's syndrome.
    • Uterine causes for abnormal uterine bleeding include fibroids (20% of women 35 years or older), adenomyosis, endometrial polyps, endometriosis, and endometrial hyperplasia.
    • Intrauterine devices can produce abnormal bleeding as can endometritis after delivery or spontaneous or therapeutic abortion.
    • Cervical disease including sexually transmitted infections, cervical polyps, and carcinoma should be considered.
    • Vaginal and vulvar disease, trauma, and injury are other possible causes of abnormal uterine bleeding.
    • Among drugs, low-estrogen contraceptives, medroxyprogesterone injection, and hormone replacement may produce intermenstrual bleeding, whereas phenothiazines can induce anovulatory cycles.
    • Smokers may have breakthrough bleeding associated with increased metabolism of estrogen.
    • The goal of treatment of anovulatory bleeding is to regulate cycles, minimize blood loss, and prevent complications.
  • Perimenopausal and Postmenopausal Women
    • Because chronic anovulation can lead to prolonged periods of unopposed estrogen, a low threshold for endometrial assessment is recommended in this population.
    • Irregular bleeding of more than 6 months and cycle length of less than 17 to 19 days are considered indications for endometrial assessment.
    • The risk for endometrial cancer in a postmenopausal woman not receiving hormone replacement therapy is approximately 10%.
    • Office-based endometrial biopsy has a false-negative rate of up to 5% to 15% while transvaginal ultrasound has a sensitivity of 90% and negative predictive value of 99%.
    • The most common sources of bleeding in postmenopausal women are atrophic vaginitis, endometrial atrophy, and endometrial polyps.

Pearls for Practice

  • Abnormal uterine bleeding should be classified as premenopausal, perimenopausal, or postmenopausal and characterized as ovulatory vs anovulatory for further workup.
  • Some of the causes of abnormal uterine bleeding in premenopausal women are related to hormonal (anovulation, hypothalamic, exogenous hormones), local (vaginal, cervical or vulvar) or systemic (coagulopathy, smoking) sources, whereas some of the causes in premenopausal and postmenopausal women focus on uterine (endometrial hyperplasia and carcinoma) and local (atrophic vaginitis, cervicitis) sources.

• From http://www.blackwell-synergy.com/doi/abs/10.1111/j.1365-2265.2007.02865.x

Clinical Endocrinology

To cite this article: Giuseppe Reimondo, Anna Pia, Barbara Allasino, Francesco Tassone, Silvia Bovio, Giorgio Borretta, Alberto Angeli, Massimo Terzolo
Clinical Endocrinology (OnlineAccepted Articles).

Screening Of Cushing's Syndrome In Adult Patients Newly Diagnosed To Have Diabetes Mellitus
  • Giuseppe Reimondo11Dipartimento di Scienze Cliniche e Biologiche, Medicina Interna I, A.S.O. San Luigi, Università di Torino,
  • Anna Pia22Endocrinologia, A.S.O. S. Croce e Carle, Cuneo, Italy,
  • Barbara Allasino11Dipartimento di Scienze Cliniche e Biologiche, Medicina Interna I, A.S.O. San Luigi, Università di Torino,
  • Francesco Tassone22Endocrinologia, A.S.O. S. Croce e Carle, Cuneo, Italy,
  • Silvia Bovio11Dipartimento di Scienze Cliniche e Biologiche, Medicina Interna I, A.S.O. San Luigi, Università di Torino,
  • Giorgio Borretta22Endocrinologia, A.S.O. S. Croce e Carle, Cuneo, Italy,
  • Alberto Angeli11Dipartimento di Scienze Cliniche e Biologiche, Medicina Interna I, A.S.O. San Luigi, Università di Torino,
  • Massimo Terzolo11Dipartimento di Scienze Cliniche e Biologiche, Medicina Interna I, A.S.O. San Luigi, Università di Torino
  • 1Dipartimento di Scienze Cliniche e Biologiche, Medicina Interna I, A.S.O. San Luigi, Università di Torino, and 2Endocrinologia, A.S.O. S. Croce e Carle, Cuneo, Italy
Corresponding author: Giuseppe Reimondo, MD
Dipartimento di Scienze Cliniche e Biologiche
Università di Torino
A.S.O. San Luigi
Regione Gonzole, 10
10043 Orbassano, Italy
Tel: ++011 9026292
Fax: ++011 9038655
e-mail: g.reimondo@virgilio.it


Objective: Recent studies showed that a relatively high number of diabetic patients might have unsuspected Cushing's syndrome (CS). The aim of the present study was to screen for CS in adult patients with newly diagnosed diabetes mellitus who were not selected for clinical characteristics, such as poor control and obesity, which may increase the pre-test probability of CS.

Design, patients and measurement: We prospectively evaluated 100 consecutive diabetic patients at diagnosis from 2003 to 2004. No patient had clear Cushingoid features. Screening was performed by using the overnight 1-mg dexamethasone suppression test (DST) after complete recovery from acute concomitant illnesses and satisfactory glycaemic control attained. The threshold of adequate suppression after DST was set at 110 nmol/L.

Results: Five patients failed to suppress cortisol after DST and underwent a repeated DST and a confirmatory standard two-day 2-mg DST after 3-6 months from the baseline evaluation. In one woman, a definitive diagnosis of CS was made by a surgically proven pituitary adenoma and glycaemic control improved after cure of CS.

Conclusions: The results of the present study support the view that unknown CS is not rare among patients with diabetes mellitus. This is the first demonstration that screening for CS may be feasible at the clinical onset of diabetes in an unselected cohort of patients. Therefore, early diagnosis and treatment of CS may give the opportunity to improve the prognosis of diabetes.

Full Text PDF (73 KB) (Subscription)


• From  http://jcem.endojournals.org/cgi/content/abstract/92/4/1358

Journal of Clinical Endocrinology & Metabolism, doi:10.1210/jc.2006-2674
The Journal of Clinical Endocrinology & Metabolism Vol. 92, No. 4 1358-1363
Copyright © 2007 by The Endocrine Society

Adrenal Gland Volume and Dexamethasone-Suppressed Cortisol Correlate with Total Daily Salivary Cortisol in African-American Women

Sherita Hill Golden, Saurabh Malhotra, Gary S. Wand, Frederick L. Brancati, Daniel Ford and Karen Horton

Departments of Medicine (S.H.G., G.S.W., F.L.B., D.F.), Psychiatry (G.S.W.), and Radiology (K.H.), Johns Hopkins University School of Medicine, and Department of Epidemiology (S.H.G., F.L.B., D.F.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205; and Department of Medicine (S.M.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213

Address all correspondence and requests for reprints to: Dr. Sherita Hill Golden, Johns Hopkins University School of Medicine, Division of Endocrinology and Metabolism, 2024 East Monument Street, Suite 2-616, Baltimore, Maryland 21205. E-mail: sahill@jhmi.edu.

Context: Population-based studies of associations between subclinical hypercortisolism and risk for disease states, such as type 2 diabetes mellitus, have been difficult to assess because of imprecise measures of glucocorticoid exposure. Alternative measures (salivary cortisol and adrenal gland volume) have not been systematically compared with 24-h urine free cortisol (UFC) in a healthy population.

Objective: Our objectives were: 1) to determine whether 24-h UFC and total daily salivary cortisol correlated with each other, adrenal gland volume, and salivary cortisol after dexamethasone suppression and 2) to evaluate the association of adrenal gland volume with salivary cortisol after dexamethasone suppression.

Design, Setting, and Participants: This was a cross-sectional study of 20 healthy, premenopausal African-American women aged 18–45 yr.

Main Outcome Measures: Salivary cortisol was assessed at six time points throughout the day simultaneous with 24-h UFC collection. Adrenal gland volume was measured by computed tomography scan. Dexamethasone-suppressed salivary cortisol was measured at 0800 h after administration of 0.5 mg dexamethasone at 2300 h the prior evening.

Results: Dexamethasone-suppressed salivary cortisol levels correlated strongly with individual, timed salivary cortisol measurements, total daily salivary cortisol (rs = 0.75; P = 0.0001; n = 20), and adrenal gland volume (rs = 0.66; P = 0.004; n = 17). Total daily salivary cortisol and adrenal gland volume also correlated (rs = 0.46; P = 0.04; n = 19). In contrast, 24-h UFC levels did not correlate with any of the other hypothalamic-pituitary-adrenal axis measures.

Conclusion: A dexamethasone suppression test or adrenal gland volume may be alternative measures for characterizing subtle subclinical hypercortisolism in healthy adults.


• From  http://www.manchestereveningnews.co.uk/lifestyle/health_and_beauty/

Growing feet could mean tumour
Carmel Thomason
16/ 4/2007

LOOKING back at photos taken over the last 20 years it's clearly visible that Christine Fletcher and her twin sister, Susan Lamb are not identical as they once were.

However, the changes were so gradual that no-one really noticed. As always, friends and family told them that they could tell who was who when they were together but not when they were apart.

Even the pair themselves didn't really notice the changes. "It's something that creeps up so slowly you tend not to think much about it," explains Christine, a 57-year-old shop assistant from Manchester.

"We were always more or less the same size, but then I started to need bigger shoes than Susan - she is a size 8 and I'll take a 9 or 10. I put having big hands and feet down to being tall because I'm nearly 5ft 10, but I did notice my hands were bigger than they were because my rings were getting tight."

Real change

The growth in Christine's hands and feet as well as slight enlargement of her facial features not seen in her twin, Susan, is due to a rare condition called acromegaly.

In acromegaly the pituitary gland produces too much growth hormone, the most noticeable symptoms being hands and feet become larger, while facial features can become more coarse and prominent.

Other symptoms include sweating, soft-tissue swelling, joint disorders and, in come cases, extreme height.

Actor Richard Kiel, famous for his role as James Bond's steel-toothed nemesis, Jaws, has spoken openly about his own experience with the condition.

Like most suffers it took years before the 7ft 2ins star was diagnosed.

Slow diagnosis

However, acromegaly remains very rare, with approximately 60-70 cases per million people in the UK.

It is not hereditary and can develop at any age, although is predominately found in patients in the middle age group.

In more than 90 per cent of acromegaly cases the over-production of growth hormone is caused by a benign tumour on the pituitary gland.

The pituitary gland is located in the base of the skull, immediately under the brain and behind the eyes.

It is the controlling gland through which the brain instructs all the other major endocrine glands, producing hormones which are distributed in the body via the blood stream to control the stress response; metabolic rate; growth; milk production; sexual function and fertility.

Not ill

In Christine's case it was the production of growth hormone in her body which was disturbed. “I never felt ill with it at all,” Christine explains.

“That's why it's hard to diagnose. You can see the symptoms but they develop over such a long time I can't say how long I've had it until I look at old photographs.

Looking at 20 years ago I was the just same as my sister, but exactly when the tumour began to affect me, I don't know.”

Christine's acromegaly was picked up after the thickening of tissues in her wrist caused her to develop carpal tunnel syndrome, a common condition that occurs when there is too much pressure on a nerve in the wrist.

“I had an operation for carpal tunnel one wrist and came away not thinking any more of it,” Christine remembers.

“Then the other hand started so I had to have that one done as well. It's day surgery under local anaesthetic so when I saw the surgeon I asked if he could have a look at my hands because they seemed to have got bigger.”

Being a twin it was easy for Christine to see her probable growth by comparing the size of her hands and feet with Susan.


However, a blood test followed by an MRI scan confirmed she had a tumour on her pituitary and she was diagnosed with acromegaly.

“At first I was treated with injections to brings my growth hormone level down,” she says. “It did make my growth hormone level more normal, but it doesn't get rid of the tumour.

“I tried the injections for over a year and I knew at the end of the day the only alternative was surgery.”

Under the care of Mr Kanna Gnanalingham, a consultant Neurosurgeon at Hope Hospital, Christine underwent endoscopic pituitary surgery, a keyhole surgical technique which removes the tumour through the nose.

“I was nervous, but Mr Gnanalingham and the staff at Hope Hospital were fantastic. They were very positive and explained everything that was going to happen.

Stay over

“Afterwards I had to stay in hospital for six days while they monitored my hormone levels had gone back to normal but I didn't need any painkillers. All I had was a runny nose and I couldn't blow it for a couple of weeks so I felt a bit bunged up.

“The tumour has gone and I've got to have an MRI scan every 12 months and have check up blood tests to make sure it doesn't come back.”


After removal of the tumor hormone levels usually return to normal straight away.

Patients often find that enlarged features improve, however, where acromegaly has affected height, as in the case of actor, Richard Kiel, bone, once grown, will not reduce in size.

“I've been told that sometimes hands and feet can go back to normal but it can take as long for this to happen as it took the change to happen in the first place,” Christine adds.

“Since the operation I haven't really seen any change, but I'm keeping an open mind about it, as long as the tumour's gone that's all I'm bothered about.”

Acromegaly Masquerading as Polycystic Ovary Syndrome
Renner, Matthew MD., et al. – This case describes a growth hormone-prolactin, cosecreting pituitary microadenoma that presented with chronic, hyperandrogenic anovulation. A 37-year-old parous patient presented with 1 year of irregular cycles unresponsive to clomiphene citrate and a mildly elevated prolactin. Laboratory evaluation demonstrated hyperprolactinemia with an elevated, age-adjusted, insulin-like growth factor-1 level, and nonsuppressed growth hormone following glucose loading [more...]

The Endocrinologist, 04/13/07

• From  http://www.nytimes.com/2007/04/15/business/yourmoney/

April 15, 2007

Aging: Disease or Business Opportunity?


FOR four days last December, America’s pleasure dome in the desert, Las Vegas, played host to a convention dedicated to the proposition that growing old is “a treatable medical condition.”

Booths advertising vitamins, hormones and pharmaceutical drugs, along with an array of oxygenating or detoxifying paraphernalia, filled the exhibition hall of the Venetian Resort Hotel Casino. Lectures and workshops were offered on a bevy of “wellness” topics, including the alluring idea that human growth hormone could be deployed to beat back old age.

Several thousand attendees, mostly physicians, crowded the Venetian, a testament to what analysts say is now an industry that snares $50 billion a year in sales by catering to Americans’ obsession with looking and feeling younger. This spring, though, the anti-aging industry has come under a harsher light. The authorities have indicted 20 people, including four doctors, in three states as part of an investigation into what federal and state prosecutors describe as a booming and illegal trade: Internet trafficking in human growth hormone and anabolic steroids.

More than half of those indicted thus far in the case worked for companies that peddled their wares at the Las Vegas convention or that belonged to the trade group that organized it, the American Academy of Anti-Aging Medicine. Most of the publicity surrounding the investigations has focused on sales to athletes. But experts in government, law enforcement and the industry say human growth hormone, or HGH, is actually used much more often, and increasingly so, to slow aging.

While it has not been accused of any wrongdoing in the investigations, the academy is one of the leading preachers of growth hormone’s anti-aging powers and has as its core gospel the idea that HGH can, as its literature states, “produce striking improvements” in patients’ “health, energy level and sense of well-being.”

Since two osteopathic physicians in Chicago, Ronald M. Klatz and Robert M. Goldman, founded it 15 years ago, the academy has spun its teachings into a lucrative enterprise that claims 20,000 members, runs a Web site (www.worldhealth.net), worldwide conventions and medical education programs that award board certifications in “anti-aging regenerative medicine.” Along the way, the academy has also become a consistent focus of criticism, derided by an establishment that calls anti-aging medicine quackery or hype, says growth hormone is dangerous and labels the academy’s promotions as medically and legally specious.

“The whole idea of anti-aging medicine is controversial,” said Dr. Robert N. Butler, who was director of the National Institute on Aging, a federal agency, from 1976 to 1982. “On the good side, it encourages healthy behaviors. On the other side, it sells things like human growth hormone, which is harmful.”

Medical research has tended to support the view that growth hormone’s risks outweigh any potential anti-aging benefits. Under federal law, the substance is illegal to use except for treating childhood growth disorders, AIDS and a rare adult hormone deficiency. But Dr. Klatz and Dr. Goldman have argued that aging is a disease that causes the pituitary gland to gradually produce less growth hormone. Therefore, they say in books, articles and speeches that hormone replacement therapy at low doses is legal and beneficial in “properly diagnosed deficient adults.”

Dr. Klatz, who is 51 and the academy’s president, and Dr. Goldman, 52, its chairman, declined to be interviewed for this article. But in response to written questions through their lawyer, they said the 1990 federal law making it a felony to prescribe growth hormone for “off label” uses was aimed specifically at athletic abuse and nothing else. Neither of the doctors is mentioned in the recent indictments, and they also have not been accused of any wrongdoing in connection with the investigation.

But many of the individuals and companies cited in the indictments have been involved with the academy and its conventions over the years. Dr. Klatz and Dr. Goldman would not comment on the investigations, saying they barely knew the suspects or the nature of their businesses. They say they neither prescribe nor distribute growth hormone, and advocate doing so only in accordance with state and federal laws and after a proper physical examination, not as an Internet purchase.

They also say that pharmacies and individuals indicted in the investigation will no longer exhibit, sponsor or advertise at academy conventions and have already been removed from the academy’s Web site. Pharmacies and individuals had been paying $150 to $750 to be listed in the academy’s directory and $3,695 to $22,000 to buy display booths at its conventions.

Despite the controversy surrounding them, Dr. Klatz and Dr. Goldman have grown wealthy through their stewardship of the academy and as leading anti-aging evangelists, building their business on books like “Grow Young With HGH,” disputed science and on people’s perennial — indeed, ageless — fear of growing old. They recently sold an 80 percent stake in their conventions business for as much as $49 million to the Tarsus Group, a London media concern.

Dr. Klatz and Dr. Goldman are not afraid to take on their critics. In the last few years, they have been embroiled in legal disputes — with the State of Illinois, over offshore medical degrees they received in the late 1990s, and with professional critics whom they sued for giving them a “silver fleece” award in 2004 for promotion of questionable anti-aging products. (That suit was settled last November; its terms are confidential.)

Self-described mavericks, Dr. Klatz and Dr. Goldman dismiss their critics as biased toward “the old-school medical establishment” and say that the medical establishment’s current gerontology practices pessimistically promote “a cult of death.”

Hormones, including steroids and human-growth treatments, have captured the imaginations and bodies of athletes and others for many decades now, for the all-too-visible reason that they promote rippling, strapping muscular bulk and enhance performance. The hormone movement gained traction after a 1990 article in The New England Journal of Medicine said that a six-month study of 12 men, ages 61 to 81, who took HGH had less body fat and more lean body mass compared with a control group that did not take the hormone.

More recently, however, advocates also have promoted growth hormones as the modern fountain of youth. The expansion of the anti-aging movement is being fed by several factors — among them, graying baby boomers, growing enthusiasm for physical fitness, interest in alternative medical treatments, and, some analysts say, many doctors’ efforts to compensate for income lost to managed care. The market for drugs to control and treat diseases of aging and for appearance-related products and services is expected to reach $71 billion a year by 2009, according to BCC Research, a market research company in Wellesley, Mass.

Government and industry officials estimate that 25,000 to 30,000 Americans take injections of growth hormone for anti-aging purposes, paying up to $1,000 a month. And investigators say that the hormone, like many pharmaceuticals, is increasingly being bought on the Internet. State and federal law enforcement officials have focused on doctors who may have written prescriptions without seeing patients and on businesses that may have illegally trafficked in HGH.

Some of the legal parameters around promoting and dispensing HGH are nebulous. Steven D. Silverman, an assistant director of compliance at the Center for Drug Evaluation and Research, part of the Food and Drug Administration, says that people advocating growth hormone for anti-aging purposes “may be engaged in protected speech.” But, he adds, “if a doctor or pharmacy is actually dispensing this product for anti-aging purposes, that’s different and it may be illegal.”

Recent research underscores growth hormone’s potential dangers. This year, in the Annals of Internal Medicine, a review of 31 randomized, controlled studies concluded that “risks far outweigh benefits when it is used as an anti-aging treatment in healthy older adults.” Side effects, according to the National Institutes of Health, may include diabetes, hypertension, hardening of the arteries and abnormal growth of bones or internal organs.

FOR his part, Dr. Klatz challenges the concerns of the Annals of Internal Medicine about possible risks of HGH, contending that thousands of other studies showed “clear benefits” at lower doses; he compares using the hormone to using insulin for treating diabetics.

He says HGH slows down aging by improving lean muscle mass, reducing body fat and increasing energy. The hormone affects metabolic processes in many ways, according to Genentech, the company that developed the first synthetic growth hormone in 1981. But while Genentech and other pharmaceutical suppliers, on the advice of regulators, emphasize that HGH should be given only for government-approved uses like dwarfism, Dr. Klatz and Dr. Goldman have pushed it onto the frontiers of anti-aging.

“They have led the charge to educate in a realm that pharmaceutical companies won’t,” said Dr. Mark L. Gordon, a family practitioner in Encino, Calif. Asked how important Dr. Klatz and Dr. Goldman were in the anti-aging world, he responded: “as figureheads, extremely.”

But Dr. Stephen Barrett, a senior member of the National Council Against Health Fraud, a nonprofit advocacy group that operates the quackwatch.org Web site, says the academy has misrepresented research on growth hormone and promotes questionable products.

Dr. Barrett dismisses the medicinal value of the academy’s work and says its operations are more akin to Fort Knox than anything else. “I think it’s basically a money-making machine for Klatz and Goldman,” he said.

No mainstream medical association like the American Board of Medical Specialties or the American Medical Association recognizes the academy’s board certification — though Dr. Klatz and Dr. Goldman say they are currently asking for A.B.M.S. approval. Doctors seeking certification from the academy must pay $3,440, study three books partly written or edited by Dr. Klatz and Dr. Goldman, and pass a multiple-choice test, chart review and oral exam.

While the academy has certified hundreds of doctors, some who were once involved with the anti-aging movement have distanced themselves from the work of Dr. Klatz and Dr. Goldman. Dr. L. Stephen Coles, a researcher at the University of California, Los Angeles, recalled the excitement when he first joined the doctors and about 10 other physicians near Cancún, Mexico, in 1992 to talk about hormones and aging. Growth hormone is legal in Mexico, and some enthusiastic users lived there at the time.

“I remember saying this is really important, this is what medicine will be in the next five years,” Dr. Coles recalled. He has changed his mind. Now, he says, “Growth hormone is risky, and I’d like to see long-term studies.”

Dr. Klatz and Dr. Goldman are graduates of osteopathic colleges in Iowa and Illinois, respectively. Osteopaths, who represent about 6 percent of the nation’s licensed physicians, focus on holistic health treatments and the muscular-skeletal system and also perform functions of medical doctors like prescribing drugs and performing surgery.

Through his lawyer, Dr. Goldman said that he had received two doctoral degrees from “distance learning programs,” which he said had required “work with a mentor, textbook reading and testing.” A fitness buff, he says in a biography posted on www.worldhealth.net that he has held world records for one-armed push-ups (321) and consecutive sit-ups (13,500).

Dr. Klatz was working at a Wisconsin clinic in 1992 when he was injured in an automobile accident. After diagnosis of a cervical fracture, severe headaches, cognitive problems and a wrist injury, he spent the next six and a half years living in part on about $500,000 in disability payments, according to court records. During those years, he and Dr. Goldman, whom he first met in 1981, started the academy, working in a quasi-Gothic building in the Lincoln Park neighborhood of Chicago.

Both men received medical degrees in 1998 from the Central American Health Sciences University in Belize, without, they acknowledged, ever having studied in the country. Dr. Klatz and Dr. Goldman say through their lawyer that they earned their medical degrees with transfer credit from previous academic work and a year in clinical rotations in Mexican hospitals.

Licensing authorities in Illinois did not recognize the Belize degrees, and in 2000 fined the doctors $5,000 each for adding M.D. after their names. They agreed to a cease-and-desist order with an exception: books already printed or being reprinted with the contractual requirement that they be identified as M.D.’s. They were also allowed to continue using the M.D. designation on their résumés.

While the agreement states that they can lose their licenses for violating its terms, the doctors currently identify themselves as M.D.’s in recently published books, correspondence, their Web site and promotional materials for conferences, including one last summer in Chicago. They say through their lawyer that they are not violating the agreement because of a confidential superseding accord, but a spokeswoman for the Illinois Division of Professional Regulation says they are not permitted to designate themselves as M.D.’s in the state.

Despite having their bona fides questioned in Illinois, the doctors have been able to use the academy and its conventions to promote the anti-aging wonders of human growth hormone. Along the way, many other companies have helped make the conventions successful, and some of them have been charged with illegally trafficking in growth hormone, according to indictments handed down in state and federal investigations of the HGH business.

Among them are an Orlando concern, Signature Compounding Pharmacy, which was a sponsor and exhibitor at the Las Vegas convention; Dr. Robert G. Carlson, the medical director of the Palm Beach Rejuvenation Center, who moderated an anti-aging workshop in Las Vegas; and Dr. Claire D. Godfrey, an obstetrician-gynecologist who runs the Ageless Clinic in Orlando and gave a lecture on female hormones at the convention.

Each of those parties has pleaded not guilty to the charges. Another sponsor and exhibitor in Las Vegas, Applied Pharmacy Services, is named in a sealed indictment in Alabama, according to its lawyer, who denied that the company had engaged in any illegal activity.

IN Las Vegas last December, speakers told doctors how to diagnose mild hormone deficiencies so they could legally prescribe HGH. Dr. Gordon, the California physician, talked about diagnosing pituitary gland damage from brain trauma from slips, falls or sports injuries. A Long Island lawyer, Richard D. Collins, counseled that while growth hormone could not legally be prescribed for completely healthy people, it is permissible for disease symptoms stemming from the aging process.

Mr. Collins is now a defense lawyer for Signature Pharmacy, one of the companies indicted in the recent case. (He did not respond to interview requests.)

It is unclear what impact the investigations will have on the academy or on the careers of Dr. Klatz and Dr. Goldman — or whether it will dent the two men’s popularity in the anti-aging industry. As recently as two months ago, just before her business was raided and she was charged with illegal distribution of prescription drugs, Naomi Loomis, chief executive of Signature Pharmacy, offered a glowing testimonial saluting the academy on its Web site.

“Since our company aligned with” the academy, she noted, “our success in the age management business has grown exponentially.”

• From  http://www.virtualendocrinecentre.com/news.asp?artid=9441

Kickboxing Causes Damage To Hormone Producing Area In Brain

New research shows for the first time that kickboxing can cause brain damage. Head injuries in kickboxing can cause damage to an area of the brain called the pituitary, resulting in decreased production of hormones, which affect the body's metabolism and response to stress.

Complete Article

13 Apr 2007
Research published in the journal; Clinical Endocrinology suggests that amateur kickboxers who have suffered head injuries should be screened to ensure their pituitary is producing enough hormones.

The pituitary is a pea-sized gland, weighing one gram or less, which is found in the brain. It produces many hormones that are involved in the body's regulation of metabolism, coping with daily stress, general wellbeing and sex drive amongst other areas. A team led by Prof. Fahrettin Kelestimur at Erciyes University Medical School in Turkey measured the levels of these hormones in 22 amateur kickboxers and compared these to sex-matched healthy controls. They found that kickboxers (27.3%) suffered more than controls from hypopituitarism, a condition where the pituitary does not produce enough hormones.

Kickboxing is one of the most popular martial arts, enjoyed by approximately one million people around the world. The head is one of the most common sites of injury for both amateur and professional kickboxers. Further studies are now needed to better understand the mechanisms of hypopituitarism in head trauma patients and to develop more effective head protection gear for kickboxers.

Researcher Prof. Kelestimur said:
"This is the first time that amateur kickboxing has been shown to cause damage to the pituitary, resulting in insufficient hormone production. Our study shows that kickboxers experience an increased risk of suffering from hypopituitarism, a condition where the pituitary fails to produce enough hormones. In healthy people, hormones produced by the pituitary fulfil a critical role in helping the body maintain a healthy metabolism and cope with daily stress.

Extrapolating from our results, potentially a quarter of a million people worldwide could be producing decreased amounts of hormones as a direct result of head injuries sustained during kickboxing. We recommend that people who take part in combative sports, like boxing or kickboxing, and are exposed to repeated head trauma should be screened to ensure their pituitary is working properly."

(Source : Clinical Endocrinology : Erciyes University Medical School, Turkey : April 2007.)

• From http://neuro.psychiatryonline.org/cgi/content/full/19/2/191

ECT in Patients With Intracranial Masses
Journal of Neuropsychiatry (subscription) - USA
No deviation of the pituitary stalk or significant deformity of the diaphragma sellae was noted. She received 10 treatments without complications and with ...

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Amy (MOMMY) Amy's second MRI did not show the tiny tumor that is supposedly is in there. She has had a PSS in December 2006. The Neurosurgeon suggests transphenoidal surgery to take her whole pituitary gland. Another suggestion has been Gamma Knife. She is going to go to the Cleveland Clinic the week of April 15, 2007. Amherst, New York
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The Everything Health Guide to Thyroid Disease: Professional Advice on Getting the Right Diagnosis, Managing Your Symptoms, And Feeling Great (Everything: Health and Fitness) (Paperback)
Theodore C., M.D., Ph.D. Friedman (Author), Winnie Yu (Author)

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