Experts Recommend Tumor Removal as First-line Treatment for Cushing's Syndrome

Endocrine Society publishes Clinical Practice Guideline on treatment of chronic excess cortisol

Washington, DC–The Endocrine Society today issued a Clinical Practice Guideline (CPG) on strategies for treating Cushing's syndrome, a condition caused by overexposure to the hormone cortisol.

The CPG, entitled "Treatment of Cushing's Syndrome: An Endocrine Society Clinical Practice Guideline," was published online and will appear in the August 2015 print issue of the Journal of Clinical Endocrinology and Metabolism (JCEM), a publication of the Endocrine Society.

Cushing's syndrome occurs when a person has excess cortisol in the blood for an extended period, according to the Hormone Health Network. When it is present in normal amounts, cortisol is involved in the body's response to stress, maintains blood pressure and cardiovascular function, keeps the immune system in check, and converts fat, carbohydrates and proteins into energy. Chronis overexposure to the hormone can contribute to the development of cardiovascular disease, infections and blood clots in veins.

People who take cortisol-like medications such as prednisone to treat inflammatory conditions, including asthma and rheumatoid arthritis, can develop Cushing's syndrome. The high cortisol levels return to normal when they stop taking the medication. This is called exogenous Cushing's syndrome.

In other cases, tumors found on the adrenal or pituitary glands or elsewhere in the body cause the overproduction of cortisol and lead to the development of Cushing's syndrome. The Clinical Practice Guidelines focus on this form of the condition, known as endogenous Cushing's syndrome.

"People who have active Cushing's syndrome face a greater risk of death – anywhere from nearly twice as high to nearly five times higher – than the general population," said Lynnette K. Nieman, MD, of the National Institutes of Health's Eunice Kennedy Shriver National Institute of Child Health and Human Development in Bethesda, MD, and chair of the task force that authored the guideline. "To reduce the risk of fatal cardiovascular disease, infections or blood clots, it is critical to identify the cause of the Cushing's syndrome and restore cortisol levels to the normal range."

In the CPG, the Endocrine Society recommends that the first-line treatment for endogenous Cushing's syndrome be the removal of the tumor unless surgery is not possible or unlikely to address the excess cortisol. Surgical removal of the tumor is optimal because it leaves intact the hypothalamic-pituitary-adrenal axis, which is integral to the body's central stress response.

Other recommendations from the CPG include:

• Tumors should be removed by experienced surgeons in the following situations:
• A tumor has formed on one or both of the two adrenal glands.
• A tumor that secretes adrenocorticotropic hormone (ACTH) – the hormone that signals the adrenal glands to produce cortisol – has formed somewhere in the body other than the adrenal or pituitary gland.
• A tumor has formed on the pituitary gland itself.
• Patients who continue to have high levels of cortisol in the blood after surgery should undergo additional treatment.
• People who had an ACTH-producing tumor should be screened regularly for the rest of their lives for high cortisol levels to spot recurrences.
• If patients' cortisol levels are too low following surgery, they should receive glucocorticoid replacement medications and be educated about adrenal insufficiency, a condition where the adrenal glands produce too little cortisol. This condition often resolves in 1-2 years.
• Morning cortisol and/or ACTH stimulation tests, or insulin-induced hypoglycemia, can be used to test for the recovery of the hypothalamic-pituitary-adrenal axis in people who have low cortisol levels after surgery. Once the tests results return to normal, glucocorticoid replacement can be stopped.
• People who have undergone pituitary surgery should be re-evaluated for other pituitary hormone deficiencies during the post-operative period.
• Patients who have a pituitary tumor and have undergone surgery to remove both adrenal glands should be regularly evaluated for tumor progression using pituitary MRIs and tests for ACTH levels.
• Radiation therapy may be used to treat a pituitary tumor, especially if it is growing.  While awaiting the effect of radiation, which may take months to years, treatment with medication is advised.
• To assess the effect of radiation therapy, the patient's cortisol levels should be measured at 6- to 12-month intervals.
• Medications may be used to control cortisol levels as a second-line treatment after surgery for a pituitary gland tumor, as a primary treatment for ACTH-secreting tumors that have spread to other parts of the body or suspected ACTH-secreting tumors that cannot be detected on scans.  Medications also can be used as adjunctive treatment to reduce cortisol levels in people with adrenal cortical carcinoma, a rare condition where a cancerous growth develops in the adrenal gland.
• People with Cushing's syndrome should be treated for conditions associated with the disease, such as cardiovascular disease risk factors, osteoporosis and psychiatric symptoms.
• Patients should be tested for recurrence throughout their lives except in cases where the person had a benign adrenal tumor removed.
• Patients should undergo urgent treatment within 24 to 72 hours of detecting excess cortisol if life-threatening complications such as serious infection, pulmonary thromboembolism, cardiovascular complications and acute psychosis are present.
   

The Hormone Health Network offers resources on Cushing's syndrome at http://www.hormone.org/questions-and-answers/2012/cushing-syndrome.  

Other members of the Endocrine Society task force that developed this CPG include: Beverly M.K. Biller of Massachusetts General Hospital in Boston, MA; James W. Findling of the Medical College of Wisconsin in Milwaukee, WI; M. Hassan Murad of the Mayo Clinic in Rochester, MN; John Newell-Price of the University of Sheffield in Sheffield, U.K.; Martin O. Savage of the William Harvey Research Institute at Barts and the London School of Medicine and Dentistry in London, U.K.; and Antoine Tabarin of CHU de Bordeaux and INSERM at the University of Bordeaux, Bordeaux France.

The Society established the CPG Program to provide endocrinologists and other clinicians with evidence-based recommendations in the diagnosis and treatment of endocrine-related conditions. Each CPG is created by a task force of topic-related experts in the field. Task forces rely on scientific reviews of the literature in the development of CPG recommendations. The Endocrine Society does not solicit or accept corporate support for its CPGs. All CPGs are supported entirely by Society funds.

The CPG was co-sponsored by the European Society of Endocrinology.
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Founded in 1916, the Endocrine Society is the world's oldest, largest and most active organization devoted to research on hormones and the clinical practice of endocrinology.  Today, the Endocrine Society's membership consists of over 18,000 scientists, physicians, educators, nurses and students in 122 countries. Society members represent all basic, applied and clinical interests in endocrinology. The Endocrine Society is based in Washington, DC. To learn more about the Society and the field of endocrinology, visit our site at www.endocrine.org. Follow us on Twitter at https://twitter.com/#!/EndoMedia.

Tips for consumers to take control of their health and wellness

Are You in the Driver's Seat When it Comes to Your Health?
By Dr. Chad Larson

Dr. Chad Larson

Now more than ever people are taking charge of their own health because of easy access to the Internet that allows more people to be armed with knowledge about their health. For medical professionals this is both good and bad. It's good in that people feel more empowered than ever about their health, but bad in that access to all of that information can lead to self-diagnosis of their own ailments, which is potentially problematic. That said, taking control of one's own health by working in conjunction with a healthcare provider is the first step to improve a person's overall health.
Here are a few questions to ask yourself and tips to make sure you are in the driver's seat when it comes to your health:

1)      Are you getting an unclear diagnosis from your healthcare professional? 
If you aren't feeling well and your doctor doesn't know why, no one is in the driver's seat to your health. Due to scheduling demands, most medical professionals have a limited amount of time to spend during a patient's visit. If there isn't a clear way to diagnose your health concern with a blood test or other procedure, sometimes a process of elimination is used as a way to identify what's wrong. With all of this guesswork, it's no wonder patients often feel uncertain and uneasy with their diagnosis. In order to take charge in this situation, I suggest partnering with your healthcare provider to search for what types of tests would assist in pinpointing a clear diagnosis. There are several websites that are patient-friendly and that give consumer information about why a patient may feel unwell. Ask your healthcare provider for some options. Or, depending on your symptoms, start by searching for possible dietary and environmental triggers (often overlooked by your doctor) or use search terms such as "immunology" and "sensitivities." 

2)      Are you researching your family health history?
Do you know if your mother or father suffered from any autoimmune disorders? Do you know if they were allergic to or had food sensitivities? Write down and keep handy your health history as it pertains to your relatives. According to the American Autoimmune Related Diseases Association, 54 million people have autoimmune diseases, many of which go undiagnosed. If you have a history of autoimmune disease in your family, you are more likely to develop one yourself, according to the national institutes of health. Tracing your family health history is important and highly recommended when you want to be more in control of your health and your risk factors to disease.

3)      Are you tracking what you eat?
With genetically modified foods, increased use of pesticides, and glue or gum additives in food, food reactivity is becoming more commonly tied to feelings of overall unhealthiness. Gluten and other foods can have a huge impact on health. Ask your healthcare provider if what you are experiencing is possibly a reaction to what you are eating. This is one easy way to identify the cause of some common health issues such as brain fog, bloating, tiredness and joint pain. 

4)      Do you follow a successful exercise routine?
Exercise is a great way to get on the road to being a healthier version of yourself. Exercise has a positive effect on many chronic health concerns, including body weight issues. Conversely, remaining overweight or obese can lead to major problems like diabetes, high blood pressure and heart disease. Talk to your healthcare provider about your health and about beginning an exercise routine.
With so much information about health at your fingertips, it is easy to get overwhelmed and frustrated by not knowing why you are feeling unhealthy. Remember that partnering with your healthcare provider and being an advocate for yourself is the first step on the road to wellness. The questions to consider and tips above can help empower you to a healthier and happier lifestyle while putting you in control of one—if not the most—important things in your life – your health. 

Dr. Larson, advisor and consultant to Cyrex Laboratories, holds a Doctor of Naturopathic Medicine degree from Southwest College of Naturopathic Medicine and a Doctor of Chiropractic degree from Southern California University of Health Sciences. He is a Certified Clinical Nutritionist and a Certified Strength and Conditioning Specialist. He particularly pursues advanced developments in the fields of endocrinology, orthopedics, sports medicine, and environmentally-induced chronic disease. Cyrex is a clinical immunology laboratory specializing in functional immunology and autoimmunity. Cyrex offers multi-tissue antibody testing for the early detection and monitoring of today's complex autoimmune conditions. Cyrex develops innovative testing arrays through continuous collaboration with leading experts in medical research and clinical practice. Cyrex differs from other labs by offering four pillars of excellence, including antigen purity, optimized antigen concentration, antigen-specific validation and parallel testing technology. Cyrex is based in Phoenix, Arizona and is a CLIA licensed laboratory. For more information please visit joincyrex.com/patients.

News Briefs from the Endocrine Society

Journal of Clinical Endodcrinology
& Metabolism (JCEM)

1. Prenatal DDT Exposure Tied to Nearly Four-fold Increase in Breast Cancer RiskFifty year-long study first to directly connect breast cancer risk to in utero chemical exposure

Women who were exposed to higher levels of the pesticide DDT in utero were nearly four times more likely to be diagnosed with breast cancer as adults than women who were exposed to lower levels before birth, according to a new study published in the Endocrine Society's Journal of Clinical Endocrinology & Metabolism (JCEM). A more estrogenic form of DDT that is found in commercial DDT, o,p'-DDT, was largely responsible for this finding.

Despite being banned by many countries in the 1970s, DDT remains widespread in the environment and continues to be used in Africa and Asia. Many women who were exposed in utero in the 1960s, when the pesticide was used widely in the United States, are now reaching the age of heightened breast cancer risk.

DDT was among the first recognized endocrine disruptors, according to the introductory guide to endocrine-disrupting chemicals published by the Endocrine Society and IPEN. DDT and related pesticides can mimic and interfere with the function of the hormone estrogen. Past studies have found DDT exposure is linked to birth defects, reduced fertility and increased risk of Type 2 diabetes.

"This 54-year study is the first to provide direct evidence that chemical exposures for pregnant women may have lifelong consequences for their daughters' breast cancer risk," said one of the study's authors, Barbara A. Cohn, PhD, of the Public Health Institute in Berkeley, CA. "Environmental chemicals have long been suspected causes of breast cancer, but until now, there have been few human studies to support this idea."

The case-control study is prospective, having tracked the daughters of women who participated in the Child Health and Development Studies (CHDS) for 54 years beginning in utero. CHDS studied 20,754 pregnancies among women who were members of the Kaiser Foundation Health Plan from1959 through 1967. CHDS participants gave birth to 9,300 daughters during that period.

For the analysis published in JCEM, researchers used state records and a survey of CHDS participants' grown daughters to determine how many were diagnosed with breast cancer by age 52. To determine levels of DDT exposure in utero, the researchers analyzed stored blood samples from CHDS to measure DDT levels in the mothers' blood during pregnancy or in the days immediately after delivery. The researchers measured DDT levels in mothers of 118 women who were diagnosed with breast cancer. The scientists identified 354 daughters who did not develop cancer to use as controls and tested their mothers' blood for comparison.

The researchers found that independent of the mother's history of breast cancer, elevated levels of o,p'-DDT in the mother's blood were associated with a nearly four-fold increase in the daughter's risk of breast cancer. Among the women who were diagnosed with breast cancer, 83 percent had estrogen-receptor positive breast cancer, a form of cancer that may receive signals from the hormone estrogen to promote tumor growth.

Researchers also determined that exposure to higher levels of o,p'-DDT was associated with women being diagnosed with a more advanced stage of cancer. In addition, the scientists found women with greater exposure to o,p'-DDT were more likely to develop HER2-positive breast cancer, where the cancer cells have a gene mutation that produces an excess of a specific protein. Basic research studies where breast cancer cells were exposed to DDT have found the pesticide activated the HER2 protein.

"This study calls for a new emphasis on finding and controlling environmental causes of breast cancer that operate in the womb," Cohn said. "Our findings should prompt additional clinical and laboratory studies that can lead to prevention, early detection and treatment of DDT-associated breast cancer in the many generations of women who were exposed in the womb. We also are continuing to research other chemicals to see which may impact breast cancer risk among our study participants."

Other authors of the study include: Michele La Merrill of the University of California, Davis, in Davis, CA; Nickilou Y. Krigbaum, Lauren Zimmermann and Piera M. Cirillo of the Public Health Institute in Berkeley, CA; and Gregory Yeh and June-Soo Park of the California Department of Toxic Substances Control in Berkeley, CA.

The research was supported with funding from the California Breast Cancer Research Program, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of Environmental Health Sciences, the California Public Health Department, the National Cancer Institute's Surveillance, Epidemiology and End Results Program, and the U.S. Centers for Disease Control and Prevention's National Program of Cancer Registries.

The study, "DDT Exposure in Utero and Breast Cancer," will be published online at http://press.endocrine.org/doi/10.1210/jc.2015-1841, ahead of print.

2. Maternal Stress Alters Offspring Gut and Brain through Vaginal Microbiome
Stress may have negative immunologic, nutritional and metabolic effects

Changes in the vaginal microbiome are associated with effects on offspring gut microbiota and on the developing brain, according to a new study published in Endocrinology, a journal of the Endocrine Society.The neonate is exposed to the maternal vaginal microbiota during birth, providing the primary source for normal gut colonization, host immune maturation, and metabolism. These early interactions between the host and microbiota occur during a critical window of neurodevelopment, suggesting early life as an important period of cross talk between the developing gut and brain.

"Mom's stress during pregnancy can impact her offspring's development, including the brain, through changes in the vaginal microbiome that are passed on during vaginal birth," said one of the study's authors, Tracy Bale, PhD, of the University of Pennsylvania. "As the neonate's gut is initially populated by the maternal vaginal microbiome, changes produced by maternal stress can alter this initial microbe population as well as determine many aspects of the host's immune system that are also established during this early period."

In this study, researchers utilized an established mouse model of early maternal stress, which included intervals of exposure to a predator odor, restraint, and novel noise as stressors. Two days after birth, tissue was collected from the moms using vaginal lavages and maternal fecal pellets and offspring distal gut were analyzed. Offspring brains were examined to measure transport of amino acids. Researchers found stress during pregnancy was associated with disruption of maternal vaginal and offspring gut microbiota composition.

These findings demonstrate the important link between the maternal vaginal microbiome in populating her offspring's gut at birth, and the profound effect of maternal stress experience on this microbial population and in early gut and brain development, especially in male offspring.

"These studies have enormous translational potential, as many countries are already administering oral application of vaginal lavages to c-section delivered babies to ensure appropriate microbial exposure occurs," Bale said. "Knowledge of how maternal experiences such as stress during pregnancy can alter the vaginal microbiome is critical in determination of at-risk populations."

Other authors of the study include: Eldin Jašarević, Christopher Howerton and Christopher Howard of the University of Pennsylvania.

The study, "Alterations in the vaginal microbiome by maternal stress are associated with metabolic reprogramming of the offspring gut and brain," will be published online at http://press.endocrine.org/doi/10.1210/en.2015-1177, ahead of print. 

3. Hormone Fluctuations Disrupt Sleep of Perimenopausal WomenStudy finds sleep interruptions worsen during certain phases of menstrual cycle

Women in the early phases of menopause are more likely to have trouble sleeping during certain points in the menstrual cycle, according to a new study published in the Endocrine Society's Journal of Clinical Endocrinology & Metabolism.During perimenopause – the earliest stage of the menopausal transition – women may have irregular menstrual cycles due to the body's fluctuating hormone levels. Symptoms such as sleep disturbances and hot flashes typically begin three to five years prior to the onset of menopause, when a woman is in her 40s, according to the Hormone Health Network.

The study examined how hormone fluctuations affected sleep during the luteal and follicular phases of the menstrual cycle. The luteal phase occurs prior to menstruation. The follicular phase refers to the two weeks after menstruation.

"We found that perimenopausal women experience more sleep disturbances prior to menstruation during the luteal phase than they did during the phase after menstruation," said one of the study's authors, Fiona C. Baker, PhD, of the Center for Health Sciences at SRI International in Menlo Park, CA, and the University of the Witwatersrand in Johannesburg, South Africa. "Measures of electrical brain activity found that the hormone progesterone influences sleep, even at this late reproductive stage in perimenopausal women."

The laboratory study examined sleep patterns in 20 perimenopausal women. Eleven of the participants experienced difficulty sleeping at least three times a week for at least a month, beginning with the onset of the menopausal transition.

The women each slept in a sleep laboratory twice – once in the days leading up to the start of the menstrual period and the other time several days after the menstrual period. Researchers used an electroencephalogram (EEG) to assess the women's sleep and brain activity. Each participant also completed a survey regarding their sleep quality in the month prior to the laboratory testing and underwent a blood test to measure changes in hormone levels.

Researchers found women had a lower percentage of deep, or slow-wave, sleep in the days before the onset of their menstrual periods, when their progesterone levels were higher. The women also woke up more often and had more arousals – brief interruptions in sleep lasting 3 to 15 seconds – than they did in the days after their menstrual periods. In contrast, sleep tends to be stable throughout the menstrual cycle in younger women.

"Menstrual cycle variation in hormones is one piece in the overall picture of sleep quality in midlife women," Baker said. "This research can lead to a better understanding of the mechanisms behind sleep disturbances during the approach to menopause and can inform the development of better symptom management strategies."

Other authors of the study include: Massimiliano de Zambotti, Adrian R. Willoughby, Stephanie A. Sassoon and Ian M. Colrain of the Center for Health Sciences at SRI International.

The study, "Menstrual-cycle Related Variation in Physiological Sleep in Women in the Early Menopause Transition," will be published online at http://press.endocrine.org/doi/10.1210/jc.2015-1844, ahead of print.

4. New from the Hormone Health Network: Exercise Anytime, Anywhere

Work out at work! The Hormone Health Network's newest infographic, "Exercises: Anytime, Anywhere" provides examples of simple physical activities that you can do no matter where you are, and how exercise can help those with diabetes. Go online to see the entire Infographics series. 

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Founded in 1916, the Endocrine Society is the world's oldest, largest and most active organization devoted to research on hormones and the clinical practice of endocrinology. Today, the Endocrine Society's membership consists of over 18,000 scientists, physicians, educators, nurses and students in 122 countries. Society members represent all basic, applied and clinical interests in endocrinology. The Endocrine Society is based in Washington, DC. To learn more about the Society and the field of endocrinology, visit our site at www.endocrine.org. Follow us on Twitter at https://twitter.com/#!/EndoMedia.

News Briefs from The Endocrine Society: Vitamin D Deficiency and PFC Exposure

1. Routine Tasks Pose Problems for Older Individuals with Vitamin D Deficiency 

2. PFC Exposure Tied to Altered Thyroid Function
3. Overcoming Anorexia

1. Routine Tasks Pose Problems for Older Individuals with Vitamin D Deficiency  

Study suggests vitamin D supplements could help prevent mobility problems
Vitamin D-deficient older individuals are more likely to struggle with everyday tasks such as dressing or climbing stairs, according to a recent study accepted for publication in The Endocrine Society's Journal of Clinical Endocrinology & Metabolism (JCEM).

Scientists estimate many as 90 percent of older individuals are vitamin D deficient. The vitamin – typically absorbed from sunlight or on a supplementary basis through diet – plays a key role in bone and muscle health. Vitamin D deficiency can lead to a decline in bone density, muscle weakness, osteoporosis or broken bones.

"Seniors who have low levels of vitamin D are more likely to have mobility limitations and to see their physical functioning decline over time," said the study's lead author, Evelien Sohl, MSc, of VU University Medical Center inAmsterdam, theNetherlands. "Older individuals with these limitations are more likely to be admitted to nursing homes and face a higher risk of mortality."

Using data from an ongoing Dutch cohort study (The Longitudinal Aging Study Amsterdam), the researchers examined among two groups – 762 people between the ages of 65 and 88, and 597 people between the ages of 55 and 65 – over the course of six years. Using blood test results, the subjects were split into groups with the highest, moderate and lowest vitamin D levels. To assess mobility limitations, participants were asked about their ability to perform routine tasks, including sitting down and standing up from a chair or walking outside for 5 minutes without resting.

Among the older group of participants, people with the lowest vitamin D levels were 1.7 times more likely to have at least one functional limitation compared to those with the highest vitamin D levels. In the younger cohort, individuals with low vitamin D levels were twice as likely to have at least one physical limitation.

While the majority of the people in the older cohort's top two vitamin D groups did not report any physical limitations, 70 percent of the people with the lowest vitamin D levels had at least one limitation.

In addition, the study found vitamin D-deficient individuals were more likely to develop additional limitations over time. The older cohort reported more mobility issues after three years, while the younger cohort developed additional limitations over the course of six years.

"The findings indicate low vitamin D levels in older individuals may contribute to the declining ability to perform daily activities and live independently," Sohl said. "Vitamin D supplementation could provide a way to prevent physical decline, but the idea needs to be explored further with additional studies."

Other researchers working on the study include: N. van Schoor, R. de Jongh, M. Visser, D. Deeg and P. Lips of the VU University Medical Center.

The article, "Vitamin D Status is Associated with Functional Limitations and Functional Decline in Older Individuals," was published online July 17.

2. PFC Exposure Tied to Altered Thyroid Function 

Endocrine-disrupting chemicals may increase odds of women developing mild hypothyroidism

Exposure to perfluorinated chemicals is linked to changes in thyroid function and may raise the risk of mild hypothyroidism in women, according to a recent study accepted for publication in The Endocrine Society's Journal of Clinical Endocrinology & Metabolism (JCEM).

Perfluorinated chemicals, or PFCs, are compounds used to manufacture fabrics, carpets, paper coatings, cosmetics and a variety of other products. Among humans and wildlife, PFC exposure is widespread, according to the National Institutes of Health's National Institute of Environmental Health Sciences. Because these chemicals break down very slowly, it takes a long time for PFCs to leave the body.

"Our study is the first to link PFC levels in the blood with changes in thyroid function using a nationally representative survey of American adults," said one of the study's authors, Chien-Yu Lin, MD, PhD, of En Chu Kong Hospital in Taiwan.

Women who had higher levels of a PFC called perfluorooctanoate (PFOA) in their blood tended to have elevated levels of the thyroid hormone triiodothyronine (T3). The study also found an increase in levels of T3 and the thyroid hormone thyroxine (T4) in women with higher concentrations of the PFC perfluorohexane sulfonate (PFHxS) in their blood. The levels rose without the pituitary gland signaling the thyroid to produce more hormones, which is the body's natural mechanism for adjusting thyroid hormone levels. Men exposed to higher amounts of PFHxS, however, tended to have lower levels of the T4 hormone.

Even though people with a history of thyroid diseases were excluded from the study, researchers found an association between subclinical, or mild, hypothyroidism and elevated levels of PFOA, PFHxS and perfluorooctane sulfonate (PFOS) in women. Hypothyroidism occurs when the thyroid gland does not produce enough hormones and can cause symptoms such as fatigue, mental depression, weight gain, feeling cold, dry skin and hair, constipation and menstrual irregularities. This relationship needs to be explored and confirmed through additional research, Lin said.

The researchers analyzed data from 1,181 participants in the 2007-2008 and 2009-2010 National Health and Nutrition Examination Survey (NHANES), a population-based survey conducted by the Centers for Disease Control and Prevention (CDC). The study reviewed levels of four different PFCs as well as thyroid function.

"Although some PFCs such as PFOS have been phased out of production by major manufacturers, these endocrine-disrupting chemicals remain a concern because they linger in the body for extended periods," Lin said. "Too little information is available about the possible long-term effects these chemicals could have on human health."

Other researchers working on the study include: L. Wen of En Chu Kong Hospital, L. Lin and T. Su of National Taiwan University Hospital and P. Chen of National Taiwan University College of Public Health.

The article, "Association between Serum Perfluorinated Chemicals and Thyroid Function in U.S. Adults: the National Health and Nutrition Examination Survey 2007-2010," was published online July 17.

3. Overcoming Anorexia

Anorexia nervosa is a serious and potentially life-threatening condition. The Hormone Health Network's patient education fact sheet Anorexia describes the risk factors for this condition and explains the serious health problems it may cause, including heart complications, dehydration and malnutrition, anemia, and tooth decay. The fact sheet outlines risk factors for and warning signs of anorexia, and encourages patients and their loved ones to get help from a team of health care providers, including a physician, mental health professional and dietician.

### Founded in 1916, The Endocrine Society is the world's oldest, largest and most active organization devoted to research on hormones and the clinical practice of endocrinology.  Today, The Endocrine Society's membership consists of over 16,000 scientists, physicians, educators, nurses and students in more than 100 countries. Society members represent all basic, applied and clinical interests in endocrinology. The Endocrine Society is based in Chevy Chase, Maryland. To learn more about the Society and the field of endocrinology, visit our site at www.endocrine.org. Follow us on Twitter at https://twitter.com/#!/EndoMedia.