Benign Incidentalomas of the Adrenals are Common and Cause TroubleJanuary 09, 2022
"Benign" Incidental Tumors on Adrenal Glands are Common
This is a hugely important study that may go a very long way to explaining puzzling conundrums in menopausal women. Most notably, "Why can't I lose weight?" or "Why do I have high blood pressure suddenly out of the blue?". You may have never heard of an "adrenal incidentalomas" but it is what its name sounds like: an incidental nodule or "mass" on the adrenal gland, found, by chance with a CT or MRI of the abdomen that includes the adrenal glands. As CT and MRI scanning has become more widespread, more of these incidental adenomas (lumps) have been found. A surprising number of them (2/3rds) appear to be in post-menopausal women.
It's the link to MACS (Mild Autonomous Cortisol Secretion) that was the impetus to this study. Cushing's Disease is most commonly caused by a "benign" tumor that excretes unregulated cortisol. Those folks show a classic picture of high blood pressure, weight gain, stretch marks, buffalo humps on their backs, and muscle weakness: all effects of too much cortisol. The question to be answered was whether there is a continuum of this archetype disease to a milder form, MACS, associated with these incidental "swellings" that hadn't become a defined mass or tumor.
They found 1305 of incidentaloma patients and evaluated them for MACS and sure enough, there was a very strong association between the tumors and the cortisol, particularly if the women had resistant diabetes needing insulin and high blood pressure needing extra medications.
In fact, the numbers were striking. In Great Britain alone, the results of this study suggested that some 1.3 million women might be affected. This becomes one of the first considerations to review if post-menopausal women have high blood pressure and diabetes. Added to their evaluation should now be a screening for MACS which essentially comes down to collecting a 24 hour urine for adrenal steroids. So, it is a continuum with Cushing's. There is a milder form. And the "milder" form may not be so benign or mild.
What has yet to be determined is whether these women all need CT/MRI's of their adrenal glands. We need clear guidelines as to what are acceptable limits of cortisol production on 24 hour urine tests. A lot of health care system training is in order.
Cushing’s disease gets severe osteoporosis. Does MACS? Yes! Do we need to checkevery woman with osteoporosis? That same thread is going to now arise with diabetes, high blood pressure, sarcopenia, weight gain.......on and on. This is a seismic shift. Huge advance. Good work, team!
WWW.What will work for me? It's not often that a major shift in disease management comes along. This is one. My ears are burning with memories of women who I have seen who have asked the question, "Might I have Cushing's?" and on standard testing, they fell through the cracks. Now we have new criteria and a new "syndrome", a complex of tests to explain. Once again, the "patient" was right. Fortunately, someone in Great Britain paid attention. It just has to be part of our workup in standard internal medicine.
1. MACS stands for what? Answer: Mild autonomous cortisol secretion.
2. Where is it found? Answer: For now, it is found in post-menopausal women who have high blood pressure and or diabetes which are slightly treatment-resistant.
3. How common is this? Answer: In women in Great Britain, the guestimate is 1.3 million women (2% at age 50 rising to 10% at age 70). That would translate into 8 million + women in the USA. A lot.
4. What are other symptoms that might be part of the syndrome? (Think what symptoms go along with Cushing's disease?). Answer: Osteoporosis, stubborn obesity particularly in the core body, sarcopenia, besides the resistant high glucose and blood pressure.
5. How do we diagnose MACS? Answer: A one-time cortisol won't define it. We will have to get 24-hour urine collections to see the totality of cortisol production, and then be more open to further testing with more nuanced parameters for the rest of the testing.
6. What's the treatment? Answer: Surgery to remove it? Yet to be determined. We don't know what is the chicken and what is the egg. What caused it? Can that be reversed? Are their effective, non-toxic drugs? Will lifestyle changes work?
Written by Dr. John Whitcomb, MD at Brookfield Longevity, Brookfield, Wisconsin