Recognise the red flags of high cortisol1
Mild or gradual hypercortisolism often presents with non-specific features that overlap with more common conditions such as:
- Obesity
- Polycystic ovarian syndrome
- Depression1
But in the presence of key signs:
- Moon face
- Low bone density
- Muscle weakness
it’s time to consider Cushing’s Syndrome.1 This guide helps you identify, investigate and act with confidence.
Signs and symptoms of Cushing’s Syndrome (CS)*
*Symptoms appear in random order.
Facial rounding (moon face)
Facial rounding, referred to as moon face or cortisol face, is caused by swelling and fat redistribution around the eyes and cheeks. Moon face is a frequent and specific feature of CS occurring in ≤90% of patients.2
Easy bruising and slow wound healing
Patients with CS often develop thin, fragile skin that bruises easily and heals slowly—even after minor or unnoticed injuries.2-4 Thin skin and easy bruising are specific, but less common features of CS, occurring in ~50% and ~40% of patients, respectively.2
Skin striae (purple stretch marks)
Skin striae due to hypercortisolism are often wide and purple, which contrasts with the narrow and pale or pink striae of rapid weight gain.5 They can occur on the thighs, flanks, lower abdomen, upper limb root or breasts. They are a specific, but less common feature of CS, occurring in <50% of patients.2
Low bone density and fragility fractures
Osteopenia or osteoporosis and fragility fractures are a hallmark feature of CS, with up to 80% of patients experiencing these features.2,3
Muscle weakness
Patients with proximal muscle weakness develop difficulty with movements such as climbing stairs, rising from a chair, lifting objects, or combing their hair. Proximal muscle weakness is a frequent and specific feature of CS occurring in 60-80% of patients.2
Dorsocervical fat pad (buffalo hump)
One of the striking features of CS is the “buffalo hump”,1 which describes the dramatic accumulation of fat in the dorsocervical region of the body. It is a specific, but less common feature of CS, occurring in ~50% of patients.2
Mood disorders (depression or anxiety)
Certain mood disorders such as depression and anxiety disorders can be associated with mild hypercortisolism.1 Depression is a frequent, but non-specific feature of CS, with 50-80% of patients reporting depressed mood.2
Moderate to severe fatigue
Moderate to severe fatigue is a frequent but non-specific symptom in CS associated with the effects of excess cortisol on metabolism and muscle tissue.6
Frequent and nonspecific signs or symptoms
Patients with CS will frequently present with these symptoms that overlap with other conditions such as obesity, polycystic ovarian syndrome, metabolic syndrome, uncontrolled diabetes and psychiatric disorders.2
- Recent weight gain (70-95%)
- Plethora (70-90%)
- Menstrual irregularities, oligo or amenorrhea (70-80%)
- Hypertension (60-90%)
- Depression (50-80%)
- Hirsutism (50-75%)
- Sleep disorders (~60%)
- Dyslipidaemia (40-70%)
- Decreased libido (25-90%)
- Cognitive impairment (prevalence unknown)
- Vitamin D deficiency (prevalence unknown)
Less frequent and nonspecific signs or symptoms
Patients with CS will sometimes present with these symptoms that overlap with other conditions such as obesity, polycystic ovarian syndrome, metabolic syndrome, uncontrolled diabetes and psychiatric disorders.2
Kidney stones
(≤50%)
(≤50%)
Diabetes
(~30%)
(~30%)
Atherosclerosis
(~30%)
(~30%)
Acne
(<50%)
(<50%)
Hair loss
(30%)
(30%)
Diagnose Cushing’s Syndrome
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Abbreviations: CS, Cushing’s Syndrome.
References: 1. Nieman LK, et al. Eur J Endocrinol 2015;173(4):M33-M38. 2. Reincke M, Fleseriu M. JAMA 2023;330(2):170-81. 3. Nieman LK, et al. Clin Endocrinol Metab 2008;93(5):1526-40. 4. Caffarini M, et al. Front. Cell Dev. Biol. 7:227. 5. Stratakis CA. Rev Endocr Metab Disord 2016;17(3):283-6. 6. Page-Wilson G, et al. Pituitary 2023;26:364-74.
Date of preparation: March 2026 | AU-IST-0062
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