Cushing syndrome is one among the cause for atisthūla. Cushing's syndrome, also known as hypercortisolism, and hyperadrenocorticism, is a collection of signs and symptoms due to prolonged exposure to cortisol.
Aetiological factors
Iatrogenic cause:
taking glucocorticoids prescribed by a health care practitioner to treat other diseases. This can be an effect of corticosteroid treatment of a variety of disorders such as asthma and rheumatoid arthritis, or in immunosuppressant after an organ transplant. Cushing's syndrome in childhood usually results from use of glucocorticoid medication.
Endogenous cause:
Pituitary corticotrope adenomas account for 70% of patients with endogenous causes of
Ectopic tumor ACTH production: cortisol-producing adrenal adenomas, adrenal carcinoma, and adrenal hyperplasia account for the other causes; rarely, ectopic tumor CRH production is encountered. Tumors outside the normal pituitary-adrenal system can produce ACTH (occasionally with CRH) that affects the adrenal glands.
Pseudo-Cushing's syndrome: Elevated levels of total cortisol can also be due to estrogen found in oral contraceptive pills that contain a mixture of estrogen and progesterone, leading to Pseudo-Cushing's syndrome
.
Pathophysiology
Paraventricular nucleus (PVN) of the hypothalamus
(pran vayu analyze the situation)
(udan vayu by its prayatna and urja karma alongwith pranvayu helps in release of hormone)
Corticotropin-releasing hormone (CRH) Stimulates the pituitary gland to release Adrenocorticotropin (ACTH)Travels via the blood
(vyano rasa dhaturhi vikshepa uchit karmanaha)
Adrenal gland ACTH stimulates the release (Samana) Cortisol Elevated levels of cortisol if able to analyze by udan vayu Exert Negative feedback If unable to analyze by udan vayu CRH in the hypothalamus Hypercortisolism ACTH released from the anterior pituitary gland.Cushing Syndrome Normal Cortisol level Apan excretes and neutralizes the effect of Cortisol in blood
Signs & Symptoms
Rapid weight gain:
Meda eva upachiyate na tatha itare dhatawa. Chala sphika sthana udara lambhana (central obesity) are the features of sthaulya.
Dalhan says meda janan (lipogenesis) occurs either due to aahar, adrishta vashad medasa avrita marga tvatcha i.e. due to then unknown reason wherein meda causes avaran of vata dosha leading to adipose deposition, particularly on the trunk and face with sparing of the limbs.
Thin and fragile skin:
As upachaya of only meda dhatu takes place the mansa, rakta get depleted thereby hampering the lepana, and jeevan karma of mansa, and rakta respectively. This reduces the tensile strength of skin and makes it thin and fragile.
Purple or red striae:
The weight gain in Cushing's syndrome stretches the skin, which is thin and due to weakening and rupture of collagenous fibers (lepan karma of mansa is hampered) in the dermis.
Easy bruising and ecchymosis (tiryaka vata pradhan raktapitta):
Dilation of capillaries and thinning of the skin and mucous membranes leads to easy bleeding.
Proximal muscle weakness (hips, shoulders)
is observed due to excessive protein catabolism. Caraka mentions that daurbalya is due to asamatva dhatunam i.e. anabolism of meda continues whereas catabolism of anya dhatu like mansa, asthi etc dhatu is observed.
Osteoporosis:
is also an issue in Cushing's syndrome since osteoblast activity is inhibited. Mulasthan of asthivaha srotas is meda and jangha. Vikruta Meda causes reduced poshakansa for asthi dhatu causing asthi kshaya i.e. protein matrix of bone is loss and there is increased of calcium excretion. Further asthi and vata has ashrayashrayi sambandha therefore when asthi kshaya takes place vata vridhi occurs leading to asthi sandhi shool. Cushing's syndrome may cause sore and aching joints, particularly in the hip, shoulders, and lower back. The fractures heal badly and are accompanied by excessive callus formation.
Hirsutism (facial male-pattern hair growth)
baldness and/or extremely dry and brittle hair are observed due to excess of androgens. Androgen excess in women leads to increased hair growth in most androgen sensitive sites except in the scalp region, where hair loss occurs because androgens cause scalp hairs to spend less time in the anagen phase.
As discussed above since asthiposhakansa are less in quantity asthi kshaya takes place (depleting the concentration of calcium in the bone causing hairfall) and leading to increase of asthimala bhag (kesha and smashru vridhi). Role of rasa dhatu also needs to be studied as sukumar loma are rasa sara lakshana and Sushrut has mentioned rasa as cause for sthaulya and karshya.
Decreased fertility in men:
Charaka mentions shukra abahutvat and medasa avritta marga to be cause for kricha vyavayata. Sushruta says due to sthaulya kapha and meda causes obstruction (nirudha) of shukra marga leading to alpa vyavaya (loss of libido) and since other than meda dhatu apyayana of other dhatu does not takes place leading to shukra kshaya leading to decreased fertility. Androgen is the cause for decreased fertility in male. Androgens are hormones (vata dharmi) and if one vata prakar is vitiated it can also vitiate the gati of other vayu prakar. In this case it is avritta apan.
Menstrual disorders:
such as amenorrhea/ oligomenorrhoea in women due to excess androgen: Due to rasa dushti and rakta and shukra alpata leads to alpa raja srava. Avritta vata as discuss above may also be the cause. Studies have also shown that the resultant amenorrhea is due to hypercortisolism, which feeds back onto the hypothalamus resulting in decreased levels of GnRH release (tantra yantra dhara karma of vata is loss and also balance functioning of panchatma vayu is disturbed)
Immune suppression:
Bala depends on dhatu (dharanat dhatawa) as later on in the disease there is apachaya of all the dhatu leading to alpa bala.
Moodiness, irritability, or depression:
Niyanta praneta cha manasaha is karma of vata as vata gati is vitiated the prakrita karma of mana is disturbed. It also affects the memory and attention dysfunction. Rate of suicide is increasing due to such psychological changes.
Persistent hypertension due to cortisol enhancement of epinephrine's vasoconstrictive effect.
Diabetes mellitus due to Insulin resistance:
Insulin resistance is accompanied by skin changes such as acanthosis nigricans in the axilla and around the neck, as well as skin tags in the axilla. Madhumeha explained in Ch. Su. 17 and pathogenesis of atisthaulya both have kapha, meda, and avrita vata as common pathogenesis factors
.
Cushing's disease due to excess ACTH may also result in hyperpigmentation. This is due to Melanocyte-Stimulating Hormone production as a byproduct of ACTH synthesis from Pro-opiomelanocortin (POMC). Alternatively, it is proposed that the high levels of ACTH, β-lipotropin, and γ-lipotropin, which contain weak MSH function, can act on the melanocortin 1 receptor.Other symptoms include excess sweating (swedadhikya Su. Su. 15/32) and sleep disturbances.
Treatment:
Nidan parivarjanam: a) drugs like glucocorticoids should be stopped.
Cikitsā Siddhant:
‘Guru cha atarpanam’….(Ch. Su. 21/20)
Medicines and diet regimen should be such that it will do yapana (maintaining) of agni but at same time it will cause emaciation. In sthaulya, agni sandukshan (alleviated power of agni) is present which is cause for aahar shoshan leading to increased appetite. Guru aahar will prevent fast digestion of aahar and due to atarpan quality will not be doing bruhan.
Diet should be vatagna as well as shleshma and medohar.Ch.Su. 21/22.
Low-glycemic carbohydrates can also help lower cortisol levels naturally. Lower glycemic choices include brown rice, wheat bread and pasta, sweet potatoes, beans, and fruits and vegetables. Eat carbohydrates immediately following exercise to blunt the surge of cortisol that intense activity causes. High-quality sources of protein can help to decrease cortisol production. Whey protein, eggs and lean animal meats contain amino acids that are essential to survival. Other useful protein supplements include soy, rice, pea, hemp and vegetable proteins. Omega-3 fats from fish and flax seed oil can help to control stress. Fruits and vegetable contain many healthy phytonutrients and vitamins that can inhibit cortisol production. For example, vitamin C from citrus fruits and greens has been shown to be very effective at decreasing cortisol production
Medicines:Singal
Musta (Cyperus rotundas)
*Stress-Reducing Effects: Herbal mixture that included CR seems to help reduce stress- related physiological and psychological symptoms.
*Anti-Obesity Effect: Results suggest CR tuber extract has a potential as a herbal supplement for controlling body weight. Cyperus rotundus demonstrated statistically significant reduction of serum lipid profile. Decreasing Hair Growth / Role in Androgenic Hair / Essential Oil: topical application of essential oil is an effective method in treating moderate degrees of hirsutism and axillary hair, without affecting serum testosterone.
Vidanga (embelia ribes) it hampers male fertility by decreasing testosterone levels. Chakrapani refers that vidanga by prabhava reduces sthaulya.
Guduchi (Tinospora cordifolia): It decreases the plasma corticosterone levels effectively and also reduces obesity.
Haritaki(Terminalia chebula): anti-cortisol, anti-glucocorticoid, testosterone production.
Tribulus Aquaticus(Water chestnut) natural testosterone booster, strength, size, recovery, has anti-cortisol effect.
Spinach: The magnesium in these leafy greens help balance your body’s production of cortisol.
Beans and Barley: Phosphatidylserine, a phospholipid located in cell membranes, may help counteract the adverse effects of cortisol.
Amalaki(terminalia officinalis): Research has shown that vitamin C-rich produce, like oranges and kiwis, helps slow the production of cortisol.
Formulations
Vidangadi loha, Shilajatu, Agnimantha, Brihatpanchamula, Ayaskriti, Medohar guggulu, Madhu are the other drugs useful in sthaulya.
Associated Treatment
Yoga, Pranayam(breathing exercises), avoidance of excessive & daytime sleep, Vyavaya
(sexual intercource) Chinta(mental work/exercise) and vyayama(physical exercise) also play an essential role.
Exercise (aerobically and with weights): This may seem like a paradox but correct exercise, although it increases stress, will negate the effects of cortisol in the long term. The key is to not over strain and to do just enough to adequately stimulate the particular system being training (muscular or aerobic).
Cushing's Syndrome can be managed as per Ayurveda line of management effectively with eradication of the disease.
Prof. Satyendra Narayan Ojha
MD PhD (Kayachikitsa)
Director
Yashwant Ayurveda College & P.G. Training & Research Center
Kodoli, Kolhapur, Maharashtra, India.
Mobile No. +919822177155
email: drsnojha@rediffmail.com
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