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Let's get started with Addison's
and Cushing's Addison's and 

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Cushing's. 
What are they dealing with? 

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So, first and foremost, let's 
start with the beginning, 

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they're starting with the 
adrenal gland. 

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Where do the adrenal glands sit?
Well, they sit on top of the 

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kidney. 
And they have two parts to it. 

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They have the center which is 
the medulla Or as I used to call

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it in med school, mid Eula. 
So, and it was a middle and then

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you've got the cortex, which is 
the outer part. 

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The way that I would remember, 
what the cortex would produce is

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I would do salt. 
Sugar. 

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And sex. 
So from the outside in this 

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part, produces salt, sugar, and 
sex. 

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So what is the salt sugar sex? 
Mean, it's just the way I 

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remembered it. 
Salt with sodium and sodium is 

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controlled by Aldosterone. 
So aldosterone sugar cortisol, 

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right? 
So, the middle part was 

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cortisol, sex, is your 
androgens? 

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And androgens meaning estrogen 
testosterone. 

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So your sex hormones So this is 
what normally happens. 

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Normally our adrenals produce, 
Aldosterone cortisol and 

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androgens, and in the middle are
are catecholamines. 

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And what are catecholamines? 
Epinephrine. 

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And norepinephrine. 
So salt, sugar, sex will. 

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Now we know what normal is Let's
take a look at something. 

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That's abnormal. 
Let's start with Cushing's. 

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So in Cushing's, we've got 
excess cortisol. 

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We've got really, really high 
levels of cortisol. 

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Those of you that that were in 
the pharmacology crash course 

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over the weekend. 
Heard me talk about 

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corticosteroids and all their 
effects and cortisol acts just 

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like that. 
So cortisol can increase blood 

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pressure, it can increase sugar,
it can decrease bone density and

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I'll go through all of these in 
a little bit. 

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But what we've got is, we've got
increased cortisol total 

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sidenote, totally forgot to tell
you this. 

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If you have not signed up for 
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But if you're not in the course,
is that pop up is going to be a 

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really good pop up. 
So cortisol, why does this 

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cortisol increase? 
Let's see. 

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We got a tumor here. 
Let's say we got a tumor here, 

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so not just stress, stress 
increases cortisol, but this is 

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ridiculously high levels of 
cortisol. 

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We've got a tumor here, a 
primary tumor in the adrenals 

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that is increase in cortisol. 
Well, let's go up to another way

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that we can increase cortisol, 
or develop Cushing's how about 

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in the pituitary. 
The pituitary releases. 

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What? 
ACTH adrenocortical tropen 

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hormone. 
And that also can stimulate 

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cortisol. 
So if I've got a tumor here 

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that's increasing, ACTH will 
that's going to stimulate the 

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production of cortisol so I'll 
get really high cortisol. 

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So you've got one that's a tumor
right in the adrenal. 

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Second one is a tumor in the 
pituitary, that's signaling to 

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make more cortisol. 
And the third one is just 

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Exogenous, you're eating it. 
So people that are on long-term 

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steroid use So, first and 
foremost, we have to be able to 

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identify this. 
So, what types of signs and 

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symptoms? 
Are we going to see? 

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Hypertension. 
Think about people that are 

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stressed out and their cortisol 
levels go up. 

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They're going to gain weight. 
How about those moon phases? 

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They literally look like a moon.
How about abdominal striae? 

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That buffalo hump. 
Hyperglycemia. 

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Osteoporosis. 
Alright, these are some of the 

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symptoms that you're going to 
see your some of the signs that 

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you're going to see. 
So, look for them. 

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Look for them. and we've got 
increased cortisol caused by a 

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tumor of the adrenal or tumor in
the pituitary or exogenous use. 

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So what are we going to do? 
Well, first and foremost we got 

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to figure out where it's coming 
from. 

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So we're going to do labs and 
what labs are we going to check?

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Our cortisol. 
And are ACTH. so if cortisol is 

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elevated ridiculously elevated, 
and ACTH is low Then where do 

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you think this tumor lies? 
Or which one of the three do you

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think this is? 
Which one of the three, could it

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be? 
It could be two of the three. it

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could be the adrenal tumor, and 
An exogenous. 

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How do we know which one it is? 
How do we know which one it is, 

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if the labs are the same and 
what if it's an adrenal tumor, 

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what if it's exhaustion, is, how
are we going to? 

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How are we going to know? 
Ask them. 

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It's simple, as them. 
Are you taking any medication? 

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Are you taking any steroids? 
And they'll tell you, yeah, I've

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been on it since whatever 
reason, you know, and they've 

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been on it but if they're not 
taking steroids. 

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Okay, now we got to get some 
Imaging. 

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What's going on right now? 
We don't know. 

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So we have to do some 
investigation. 

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So this could be the adrenal 
tumor or exogenous Hughes. 

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Well. 
If it's a pituitary tumor, we're

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still going to see that 
increased cortisol because 

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that's what we're dealing with 
here, but we're also going to 

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see increased ACTH. 
So being able to identify it and

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knowing the difference between 
the three is very important. 

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Identify the signs and symptoms.
How are the board's going to ask

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Cushing syndrome? 
Well more than likely exactly. 

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Joe, they're gonna say select 
all that apply and what they're 

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going to want you to know is all
the signs and symptoms. 

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If they ask a question on 
Cushing's, they're going to want

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you to know all the signs and 
symptoms. 

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So understand what's going on. 
Let's talk about the different 

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things that happen with 
cortisol. 

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And the mnemonic is a. 
Big. 

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Fehb. 
So A is for increase in 

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appetite. 
Hence, the weight gain. 

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B is increase in blood pressure.
Because at high concentrations, 

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it will bind to aldosterone. 
And what do we say aldosterone 

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was? 
It was your salt so we can get 

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as some other people said, 
hypernatremia And with salt, 

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what follows saltwater. 
If I've got more salt, I've got 

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more water. 
I've got higher blood pressure, 

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But salt doesn't just increase 
by itself. 

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It goes in opposite directions. 
As what? 

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Potassium sodium, potassium 
pump. 

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So if sodium goes up, guess what
will go down? 

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Potassium. 
I is increased insulin 

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resistance. 
So if you've got increased 

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insulin resistance, will we've 
heard this pathology before, 

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what medical condition do? 
We see this in type 2 diabetes? 

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Insulin resistance type 1, we 
don't make insulin right. 

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The G is another way that we get
increased blood sugar, which is 

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gluconeogenesis, which is just 
the new formation of sugar. if 

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you break down the words, new 
formation of sugar, The FIB 

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everything in FIB is decreased. 
So let me So you get decreased 

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fibroblasts. 
Fibroblasts are used for wound 

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healing. 
They're using in tissue and 

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skin. 
So look at the stretch marks or 

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the striated that you get. 
Look at their skin thin out 

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fibroblasts decreased. 
The eye is decreased immune 

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response or inflammation. 
We use it for inflammation. 

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That's what we use steroids for 
right by decreasing 

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inflammation. 
We do that by decreasing our 

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immune response. so if we are 
decreasing our immune system 

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response, What are we 
susceptible for? 

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Infection infection infection, 
good. 

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So watch for infection. and then
decreased bone formation, and 

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the reason why is they decrease 
your osteoblasts and your 

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osteoblasts build bone, That's 
how I used to remember it. 

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The osteoblast, build bone, bone
formation decreases. 

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So you can see all the different
things. 

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That cortisol affects and now 
we've increased it. 

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So everything that's here 
whether it's increased or 

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decreased is now going to be 
Amplified. 

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Amplified. 
So now your appetites me way 

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higher. 
Your BP is me way higher, your 

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blood sugar's be way higher your
wound. 

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Healing is going to be way 
lower. 

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Your immune system is me way 
lower and your bone formation is

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going to be way lower. so now, 
We've got this is situation with

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Cushing's. 
So what are we going to do with 

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this patient? 
Well, if they've got a primary 

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or a secondary tumor, we're 
going to have to get rid of the 

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tumor. 
And if we get rid of the tumor, 

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do you think that they're going 
to produce cortisol? 

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No. 
So what are we going to have to 

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supplement? 
What they don't make steroid if 

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they're taking it and it's 
exogenous well it's kind of a 

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catch-22. 
Are Aldis going to outweigh. 

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What we're trying to suppress. 
Who knows? 

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if they need to be on steroids 
and there, it means or their 

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inflammatory process or actually
hurting them more than we can 

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control blood pressure, we can 
control the high blood sugar, we

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can control supplementation for 
bones, vitamin D and calcium We 

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can educate them to not. 
Go out into crowded places for 

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the infection, right? 
We have to look at The 

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cost-benefit analysis here and 
say, hey, look, is it worth it 

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for them to take cortisol 
long-term? 

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Well, if the disease process 
needs it. 

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Yeah, we're going to do it and 
then we'll just can't control 

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others diet exercise, give them 
some blood pressure meds. 

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Give him some type 2. 
Diabetes meds. 

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Educate them about infection and
supplementing with vitamin D and

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calcium so realistically that's 
what we got to do. 

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And that's not bad. 
If the person needs to be on an 

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exogenous corticosteroids, 
that's not a lot to control 

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versus what we could be 
suppressing, right? 

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Cool. 
Alright, so that's Cushing's. 

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Now, let's get into as hey guys.
Dr. Zeeshan here. 

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Thank you so much for joining us
on this podcast. 

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00:14:46,000 --> 00:14:49,400
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good one. 
See you, on the next podcast.