Dr. S. C. Rana | Dr. A. Mousa | Dr. V.

Bangar, Calderdale Royal Hospital, Halifax

Disorders of Hypothalmus and Pituitary.
PCOS OR CUSHINGS SYNDROME OR BOTH
Society for Endocrinology, Clinical Update 2007
Introduction: Here we describe a case that was dealt as a case of PCOS only, for about a
decade before it was discovered that she has Cushings syndrome caused by pituitary
microadenoma.
Case Report:Our patient a 45 years female had initially presented with 8-10 years history of
menstrual problems, inability to conceive, grade 3 hirsuitism, acne rash on her breasts &
back. She was diagnosed as a case of PCOS on the basis of clinical features, markedly
reduced SHBG and moderately enlarged ovaries 4.5x6 mm with multiple small follicles. In
follow-up clinic in CRH besides frustrated about her bad hirsuitism and acne she specifically
expressed her great disappointment for not able to lose any weight. On examination here
she was found having central obesity, moon face, buffalo hump and purplish abdominal
striae. Her consecutive 3 days UFCs were 746,880,966. Other blood results were normal.
Sex hormone profile consisting of LH <0.2 IU/L, FSH 2.9 IU/L, Oestadiol 163pmol/L,
Testosterone 2.2nmol/L (<2.7), and free androgen index 22.0 (<4.5), Prolactin 248mU/L (50-
700) but again decreased SHBG 10 (35-110). Random serum Cortisols done twice at 12.40
and 9.30 hours were 724 and 546 nmol/L respectively (184-623). Serum ACTH was 57ng/L
(<46) when serum Cortisol was 646 nmol/L.After overnight 2mg dexamethasone
suppression test serum Cortisol remained unsuppressed with value of 546 nmol/L. Low
dose dexamethasone suppression test using 0.5mg dexamethasone every 6 hours for 48
hours failed to suppress serum cortisol, the value was 554 nmol/L. High dose
dexamethasone suppression test using 2mg every 6 hours, serum cortisol was partially
suppressed to 181 nmol/L.After demonstrating excess of cortisol dependent on ACTH as
shown by results of tests above MRI pituitary was arranged which confirmed the diagnosis
by showing a 2.5.x2.5x3.5mm microadenoma in the right parasagital plane of anterior
pituitary as shown in the images. The patient was referred to a higher centre where after re-
assessment she has undergone pituitary surgery and histopathology of the resected tumor
has confirmed the presence of ACTH secreting anterior pituitary adenoma.
Discussion: Cushings disease is a rare condition whereas PCOS is the most common
reproductive endocrinopathy of women during their child-bearing years. Many of the
presenting features of Cushings syndrome are similar to those observed in a patient with
PCOS: obesity, insulin resistance, hyperinsulinaemia, hirsuitism, low SHBG levels, high
androgen levels etc
3
.Some studies have suggested that Cushings syndrome and PCOS
may co-exist
4
.Sometimes as probably in our case, PCOS may be a manifestation of
Cushings syndrome. Our patient had suffered from menstrual disturbances and primary
infertility reflecting anovulation along with obesity and hirsuitism. She had clinical features
which could have been explained by PCOS or Cushings syndrome. As described above, it
was important to rule out Cushings syndrome in her case, something delayed for a decade.
Although she had once seemingly high random serum cortisol level (although not the
recommended tests for screening for Cushings syndrome) which was unfortunately not
seriously considered and pursued for further appropriate tests to rule out Cushings
syndrome. Nevertheless, Cushings syndrome was considered and she was subjected to a
series of required tests to confirm a diagnosis of Cushings disease which might have been
done long before.
Conclusion: PCOS has many clinical and bio-chemical features which can be caused by
other rare conditions like hyperthecosis, CAH and Cushings syndrome. Therefore it is
important to exclude these before arriving at a diagnosis of PCOS. In our case we still
wonder whether she had PCOS to begin with and later developed Cushing disease, or she
had Cushing disease only from the start or she is having both the conditions. The
Dr. S. C. Rana | Dr. A. Mousa | Dr. V. Bangar, Calderdale Royal Hospital, Halifax
Disorders of Hypothalmus and Pituitary.
differentiation is always essential because two conditions warrant altogether different
management strategies.