I found this article especially interesting. This question was asked of a group of endos at an NIH conference a few years ago – if you saw someone on the street who looked like they had symptoms of fill-in-the disease, would you suggest that they see a doctor. The general answer was no. No surprise there.
Patients, if you see someone who looks like s/he has Cushing’s, give them a discrete card.
Spread The Word! Cushing’s Pocket Reference
Robin Writes:
This has been a concern of mine for some time. Your post spurred me on to do something I’ve been meaning to do. I’ve designed something you can print that will fit on the business cards you can buy just about anywhere (Wal-mart included). You can also print on stiff paper and cut with a paper cutter or scissors. I’ve done a front and a back.
Passengers on a London bus. Photograph: David Levene
A Spanish woman of 55, Montse Ventura, recently met the woman she refers to as her “guardian angel” on a bus in Barcelona. The stranger – an endocrinologist – urged Ventura to have tests for acromegaly, a rare disorder involving an excesss of growth hormone, caused by a pituitary gland tumour. How had the doctor made this unsolicited diagnosis on public transport? Apparently the unusual, spade-like shape of Ventura’s hands was a dead giveaway.
But how many off-duty doctors would feel compelled to alert strangers to symptoms they spot? “If I was sitting next to someone on a bus with a melanoma, I’d say something or I wouldn’t sleep at night,” says GP Mary McCullins. “We all have a different threshold for interfering and you don’t want to terrify people, but this is the one thing I’d urge a total stranger to see a doctor about.” So what other symptoms might prompt a doctor to approach someone on the street?
Moon face
Cushing’s syndrome is another rare hormone disorder which can be caused by a non-cancerous tumour in the pituitary gland. “A puffy, rounded ‘moon face’ is one of the classic signs of Cushing’s,” says Dr Steve Field, chair of the Royal College of GPs. “In a social situation, I wouldn’t just say, ‘You’re dangerously ill’ but I’d try to elicit information and encourage them to see a doctor.”
Different-sized pupils
When one pupil is smaller than the other, perhaps with a drooping eyelid, it could be Horner’s syndrome, a condition caused when a lung tumour begins eating into the nerves in the neck. This can be the first obvious sign of the cancer. “I’d encourage someone to get this checked out,” says Dr Simon Smith, consultant in emergency medicine at the Oxford Radcliffe Hospitals Trust. “People often have an inkling that something’s wrong, and you might spur them to get help sooner.”
Clubbing fingers
Some people are born with club-shaped fingers, but if, over time, they become “drumstick-like”, this could signify serious problems such as lung tumours, chronic lung infections or congenital heart disease. “Because it happens gradually, some people disregard clubbing,” says Smith. “But I’d say something because it can be an important symptom in many serious illnesses.”
Lumpy eyelids
Whitish yellowy lumps around the eyelids can be a sign of high cholesterol, a major factor in heart disease. Sometimes you also get a yellow circle around the iris. “I would suggest they got a cholesterol test with these symptoms,” says Smith. “They can do something about it that could save their life.”
Suntan in unlikely places
A person with Addison’s disease, a rare but chronic condition brought about by the failure of the adrenal glands, may develop what looks like a deep tan, even in non sun-exposed areas such as the palms. Other symptoms (tiredness, dizziness) can be non-specific so the condition is often advanced by the time it is diagnosed. Addison’s is treatable with lifelong steroid replacement therapy. “If someone was saying they hadn’t been in the sun but had developed a tan, alarm bells would ring and I’d probably ask how they were feeling,” says McCullins.
Trench mouth
Putrid smelling breath – even if the teeth look perfect – can be a sign of acute necrotising periodontitis. “I’d be able to tell when someone walks through the door,” says dentist Laurie Powell. “But people become accustomed to it and don’t notice.” Untreated, the condition damages the bones and connective tissue in the jaw. It can also be a sign of other diseases such as diabetes or Aids.
The Internet makes it so easy to develop weird and unusual diseases. Just plop a symptom into Google and suddenly you find yourself with stomach cancer, Cushing’s or other dread diseases.
Even on TV, the ads for lawyers almost convince people they might have mesothelioma and other rare illnesses that might bring you – and them! – bundles of money if you just sue someone.
Magazine ads implore you to “ask your doctor about…” this drug or that you might or might not need. Your doctor might just give it to you to keep you from asking. And there’s a needless medication that brings profit to the drug company and side effects to you.
TV shows like House and Mystery Diagnosis will show you diseases you never dreamed about.
There’s a great topic on the Power Surge message boards, What’s the worst “disease or ailment” you’ve had, where the women discuss the diseases they thought that they had, based on symptoms, what they’ve seen online, in the news but not based on reality.
I’ve done it myself. About the only time I was right was with my Cushing’s diagnosis. That one was a good call. But my thoughts of kidney cancer metastasis haven’t come true (yet, anyway!).
There’s been information online lately about Münchausen Syndrome. Wikipedia says:
“…the affected person exaggerates or creates symptoms of illnesses in themselves or their child/children in order to gain investigation, treatment, attention, sympathy, and comfort from medical personnel. In some extremes, people suffering from Münchausen’s Syndrome are highly knowledgeable about the practice of medicine, and are able to produce symptoms that result in multiple unnecessary operations. For example, they may inject a vein with infected material, causing widespread infection of unknown origin, and as a result cause lengthy and costly medical analysis and prolonged hospital stay. The role of “patient” is a familiar and comforting one, and it fills a psychological need in people with Münchausen’s. It is distinct from hypochondriasis in that patients with Münchausen syndrome are aware that they are exaggerating, whereas sufferers of hypochondriasis believe they actually have a disease.”
I think we’ve all see this, especially online. It’s so easy to sit in the comfort of ones home and add “just a little” to the symptoms, making it more impressive for the readers.
“…When I first got online, I “met” a young woman who claimed to be a vet, and offered me all kinds of advice about my cat and my tropical fish. She got cancer, slowly declined, then died. We wanted to send flowers, and maybe attend the funeral, and got her ISP to contact her family for us. To our shock, her parents said there was no funeral. She wasn’t dead, she wasn’t even sick. At least not physically. She’d pulled this kind of “pretend death” several times before, and was in therapy, but every time life got stressful, she’d do it again.
And the Internet is the ideal place for a Munchausen sufferer. With the click of a button, you can find out all kinds of information, to help you pose as anyone you want. People don’t expect to see you in person or even talk to you except by e-mail, making deception easier. And often, mailing lists, message boards, etc., will give unqualified support to their members…”
“…The Internet is hands-down the worst thing to ever happen to the medical world. With Web sites like WebMD, any paranoid hypochondriac like me can jump online, look for symptoms and immediately convince himself he has cancer or Cushing’s disease or non-Hodgkin’s lymphoma or any other of a million things.
WebMD allows you to find one symptom and then “helps” you by listing 15,000 things it could mean.
Oh my God. I do have a slight ache! That’s it. I must have a brain tumor. I’m not kidding, I recently scared myself into thinking I had cancer. It took a specialist, a CT scan and an ultra-sound to convince me otherwise…”
“…Over nearly three years, from 1998 to 2000, a woman—let’s call her Anna—posted to an online support group for people with mental illness. To the larger circle of readers, she acted mostly as friendly counselor. But to a select few, she e-mailed stories of escalating catastrophes. Her husband and two children had perished in a plane crash, she wrote. As a kid, her father had molested her, and she had suffered multiple personality disorder. Finally, she told her trusted—and trusting—confidants that she had just been diagnosed with leukemia.
Gwen Grabb, a psychotherapy intern and mother of three in Los Angeles, says the group believed Anna because she took on the role of helping others, revealing her own difficulties much later, and to an intimate audience. “She was very bright,” recalls Grabb. “She was very supportive and kind. One day, she started telling me about `the crash,’ what they found in the black box, how you could hear her daughter screaming. I had known her a year. I believed her.”
But as the tales became more elaborate and grotesque, Grabb grew suspicious. Along with another group member—Pam Cohen, a bereavement counselor in the Mid-Atlantic region—she did some research and discovered Anna was making it up. It was a shock to all, but worse than that to Cohen. “It is like an emotional rape,” she says. People may have been upset over the online life and fatal cancer of the fictional Kaycee, whose creator admitted last month she’d invented the high school character for expressive purposes. But that was geared to a general audience, however easily suckered. Pretenders like Anna hurt a much more vulnerable group—folks who may be seriously ill and are seeking help…”
So – use caution and remember that not everything you read will happen to you!
The landscape for compounded weight loss medicines is changing rapidly. Some availability depends on the state you live in. You may have heard that a U.S. federal judge has denied an injunction that would have allowed compounding pharmacies to keep making copies of Eli Lilly’s weight-loss and diabetes drugs Zepbound and Mounjaro (generic name Tirzepatide) in the United States. This was based on Lilly saying the shortage of Zepbound and Mounjaro has ended which most experts say is not true.
The Outsourcing Facility Association that filed the lawsuit said that the number of patients taking compounded GLP-1s as in the millions, so banning compounding pharmacies from providing these medicines will cause a shortage. This injunction does not current affect the Novo Nordisk’s drugs Ozempic or Wegovy (generic name Semaglutide), although it may in April 2025. Hundreds of Dr. Friedman’s patients have benefited from these compounded GLP-1s which are available in syringes allowing individual dosing that is not possible with the commercial medicines. Compounded GLP-1s do not require insurance pre-authorization and are much more affordable.
Compounding Pharmacies that Dr. Friedman works with
Dr. Friedman works with several compounding pharmacies to provide affordable and safe GLP-1 drugs that have improved patients’ health and weight. Dr. Friedman has communicated with representatives from the three compounding pharmacies he works with University Compounding Pharmacy (UCP), Strive Pharmacy and Empower Pharmacy and each pharmacy with each companies’ availability below. Dr. Friedman’s philosophy is that compounded pharmacies are supplying “Tirzepatide” and “Semaglutide” and not “Ozempic”, “Wegovy”, “Zepbound” and “Mounjaro” and that they are supplying customized dosing that are not available with the fixed doses supplied by the pharmaceutical companies.
According to the Wall Street Journal, Hims & Hers referred to a March 2 social-media post by Chief Executive Andrew Dudum saying the firm would stop selling commercially available doses in mid-May but would keep providing compounded versions if they have been getting a personalized dosing regimen. Thus, the personalized dosing regimen of GLP-1s (syringes that allow patients to adjust dosing) may allow them to continue to supply these compounds.
Legal Status as of April 1, 2025
Eli Lilly is suing two pharmacies for compounding Zepbound and Mounjaro, claiming the companies are skirting the Food and Drug Administration’s ban on the practice and luring people away from Lilly’s medicines. In lawsuits filed April 1, 2025 in Delaware and New Jersey, Lilly alleges the two companies — Strive Pharmacy and Empower Pharmacy — are falsely marketing their products as personalized versions of the drugs that have been clinically tested and are made using stringent safety standards. Lilly argues these claims are turning people toward compounded drugs and away from its FDA-approved treatments.
Tirzepatide versus Semaglutide
Overall, Dr. Friedman prefers Tirzepatide over Semaglutide as it gives more weight loss and less side effects but is currently available in CA only in the sublingual form. Dr. Friedman’s top recommendations are in red.
Siblingual Tirzepatide atUCP– is an excellent choice. Patients pay UCP. Tirzepatide injections have been discontinued but they have sublingual (under the tongue) Tirzepatide (10 mg/mL). One can start with 2.5 mg (0.25 mL) twice a week for 2 weeks, then go up to 5 mg (0.5 mL) twice a week for 4 weeks and then go up to 10 mg under the tongue twice a week, which is the final recommended dose. The price for 10 mL (lasts about 2 months) is $199. The 20 mL is $299. It needs to be refrigerated and can be used for 90 days after opening the bottle. It comes with a syringe that can withdraw the liquid from the vial and put under the tongue, where it should be held for 1 minute and then swallowed. It is best to take with a “dry” mouth and not to drink/eat for 30 minutes after administration. Because the sublingual product is new, its weight-loss properties compared to injectable Tirzepatide are not known.
Compounded Semaglutide/ B12 FIVE is available from UCP until April 22, 2025, and is available in 44 states including Califormia. A 5 mg vial that last about 2 months is $299.
Strive Pharmacy Strive Pharmacy, which compounds Semaglutide (brand name Ozempic, Wegovy), and Tirzepatide (brand name Mounjaro, Zepbound) is a 503B compounding pharmacy that offers GLP-1RAs to patients at a low price in 31 states including California. For Strive pharmacy, patients pay Dr. Friedman directly. There are several options available at Strive Pharmacy, with the common 3 options seen in this table:
Strive
How to order
Mg per vial
Use for which dose
Theoretical doses per vial*
Cost per vial*
State
Semaglutide#
2.5 mg/ml – 2 ml vial
5 mg
0.25 mg weekly for 4 weeks, then .5 mg weekly for 4 weeks, then 1 mg weekly for 2 weeks
10
$299
CA
Semaglutide/Glycine/B12
5mg/5mg/1mg/mL 2 ml vial
10 mg
0.25 mg weekly for 4 weeks, then 0.5 mg weekly for 4 weeks, then 1 mg weekly for 7 weeks
15
$299
Out of CA
Tirzepatide/Glycine/B12
10mg/5mg/500mcg/mL 2 ml vial
20 mg
1 mg (0.1 ml) weekly for 2 weeks, then 2 mg (0.2 ml) weekly for 4 weeks, then 4 mg (0.4 ml) weekly
9
$299
Out of CA
Empower compounding pharmacy ships to all states but CA, WI and IA. Patients pay Empower directly.
Semaglutide / Cyanocobalamin Injection
1/0.5 mg/mL 1 mL $94.68
1/0.5 mg/mL 2.5 mL $118.96
5/0.5 mg/mL 1 mL $132.18
5/0.5 mg/mL 2.5 mL $219.49
Tirzepatide / Niacinamide Injection
8/2 mg/mL 2.5 mL $188.20
17/2 mg/mL 2 mL $308.53
17/2 mg/mL 4 mL $559.21
Zepbound Glass Vials For those patients who insist on non-compounded preparations, Zepbound Glass Vials from Lilly Direct are an option. The cost for the 4 of the 10 mg vials is $499 for the first vial and $499 if renewed within 45 days or $699 if renewed after 45 days. Patients need to register on LillyDirect.lilly.com and purchase syringes for a small fee. Each vial is 0.5 ml, so the concentration is 2 mg/0.1 ml. Although the company discourages using the vial for multi-dosing (it doesn’t contain a preservative), one option would be to inject 1 mg (0.05 mL) weekly for 2 weeks, 2 mg (0.1 mL) weekly for 2 weeks, then 4 mg (0.2 ml) weekly. The box of 4 vials would last about 10 weeks.
Because of the different options for compounded GLP-1s, Dr. Friedman is advising his patients to make a 10-minute followup appointment to discuss options.
For more information, please read about compounded GLP-1s, and listen to listen Dr. Friedman’s original GoodHormoneHealth Webinar on November 17, 2024 on compounded Tirzepatide vs Semaglutide for patients with endocrine problems
Dr. Friedman discussed the updated situation for compounded GLP-1s at his most recent GoodHormoneHealth Webinar on Sunday March 23rd at 6:00 PM after his talk on “How can Blue Zones and Maimonides’ principles be applied to lead a healthy life for patients with endocrine problems?”
It is available on YouTube:
Protect access to compounded medications — make your voice heard. Sign the Petition!
Endocrinology is a medical specialty that focuses on the diagnosis and treatment of diseases related to hormones. Endocrinologists are experts in managing and treating diseases related to the endocrine system, which includes the thyroid, pituitary, adrenal glands, and pancreas. Endocrinologists are trained to diagnose and treat conditions such as diabetes, thyroid disorders, pituitary disorders, and other conditions related to hormones. Endocrinologists also specialize in reproductive health and fertility issues, including PCOS.
Endocrinology is a complex field that requires a deep understanding of the endocrine system and its role in regulating the body’s hormones. Endocrinologists must be able to interpret laboratory tests and understand the underlying causes of endocrine disorders. They must also be able to develop individualized treatment plans to address the specific needs of each patient.
Diagnosing PCOS and Diabetes
Endocrinologists are experts in diagnosing and managing PCOS and diabetes. PCOS is a hormonal disorder that affects the ovaries, and it is characterized by irregular menstrual cycles, excess facial and body hair, and infertility. To diagnose PCOS, an endocrinologist will perform a physical exam and order laboratory tests to measure hormone levels. The endocrinologist will also ask the patient about her symptoms and family history to determine if PCOS is the cause.
Diabetes is a chronic condition that affects the body’s ability to process sugar. To diagnose diabetes, an endocrinologist will perform a physical exam and order laboratory tests to measure blood sugar levels. The endocrinologist may also order imaging tests to check for signs of diabetes-related complications.
Treating PCOS and Diabetes
Once the endocrinologist has diagnosed PCOS or diabetes, they will develop an individualized treatment plan to address the patient’s specific needs. For PCOS, the endocrinologist may recommend lifestyle changes such as weight loss, exercise, and dietary changes to help manage symptoms. The endocrinologist may also prescribe medications to regulate hormone levels and improve fertility.
For diabetes, the endocrinologist may recommend lifestyle changes such as weight loss, exercise, and dietary changes to help manage blood sugar levels. The endocrinologist may also prescribe medications to help regulate blood sugar levels. In addition, the endocrinologist may recommend regular check-ups to monitor the patient’s progress and to adjust the treatment plan if needed.
Conclusion
Endocrinology plays an important role in managing PCOS and diabetes. Endocrinologists are experts in diagnosing and treating these conditions, and they are trained to develop individualized treatment plans that address the specific needs of each patient. By working with an endocrinologist, patients can get the help they need to manage their PCOS or diabetes and achieve their health goals.
Endocrinology is a complex field that requires a deep understanding of the endocrine system and its role in regulating the body’s hormones. An endocrinologist can help patients with PCOS and diabetes manage their conditions and achieve their health goals. By working with an endocrinologist, patients can get the help they need to manage their PCOS or diabetes and achieve their health goals.
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