Endocrine Abstracts

A 20-year-old girl presented to the endocrine clinic with a history of three stone weight gain, and development of numerous purple striae over her lower abdomen, inner thighs and upper arms, gradually progressing over a 12-month period. The onset of symptoms had coincided with the initiation of contraceptive depot medroxyprogesterone acetate, which was discontinued two months prior to her presentation. Her 9 am cortisol was <50 nmol/l.

She had a background history of well controlled asthma, not requiring steroid inhalers for past two years. She was seeing the rheumatologists because of chronic thoracic pain and was on fentanyl patches. She had received two intramuscular steroid injections for this, last of which was two years previously. There was no other history of exogenous steroid use.

She had a short synacthen test that showed an undetectable baseline cortisol, rising to 263 nmol/l after stimulation. ACTH was 11 ng/l, with normal renin, aldosterone and baseline pituitary function. She was commenced on hydrocortisone 10 mg am and 5 mg pm and a glucagon stimulation test organised a month later showed a peak cortisol of 262 nmol/l. She was reviewed 4 months later, her Cushingoid features had significantly improved and a 0900 h cortisol was 265 nmol/l. Subsequently, a repeat glucagon stimulation test showed a peak cortisol of 604 nmol/l, consistent with a complete recovery of the HPA axis. She has been off hydrocortisone for last 2 months and remains asymptomatic.

Medroxyprogesterone acetate is a widely used potent progestational agent. It has low affinity for the glucocorticoid receptor resulting in low level glucocorticoid activity and may cause a combination of cushingoid appearance with secondary adrenal insufficiency when used in large doses, as in the treatment of cancer. To our knowledge this is the first case of such syndrome occurring with very small doses of medroxyprogesterone used for contraception purposes.