Cushing syndrome

Last reviewed: 2 Sep 2023
Last updated: 10 May 2023



History and exam

Key diagnostic factors

  • facial plethora
  • supraclavicular fullness
  • violaceous striae
  • absence of pregnancy
  • menstrual irregularities
  • absence of malnutrition
  • absence of alcoholism
  • absence of physiologic stress
  • linear growth deceleration in children
More key diagnostic factors

Other diagnostic factors

  • female sex
  • hypertension
  • glucose intolerance or diabetes mellitus
  • premature osteoporosis or unexplained fractures
  • weight gain and central obesity
  • acne
  • psychiatric symptoms
  • decreased libido
  • easy bruisability
  • weakness
  • facial rounding
  • dorsocervical fat pads
  • unexplained nephrolithiasis
  • venothrombolic event
  • hirsutism
Other diagnostic factors

Risk factors

  • exogenous corticosteroid use
  • pituitary adenoma
  • adrenal adenoma
  • adrenal carcinoma
  • neuroendocrine tumors
  • thoracic or bronchogenic carcinoma
More risk factors

Diagnostic investigations

1st investigations to order

  • urine pregnancy test
  • serum glucose
  • late-night salivary cortisol
  • 1 mg overnight dexamethasone suppression test
  • 24-hour urinary free cortisol
  • 48-hour 2 mg (low-dose) dexamethasone suppression test
More 1st investigations to order

Investigations to consider

  • plasma dehydroepiandrosterone sulfate (DHEAS) level
  • morning plasma adrenocorticotropic hormone (ACTH)
  • pituitary MRI
  • adrenal CT
  • high-dose dexamethasone suppression test
  • inferior petrosal sinus sampling (IPSS)
  • CT of chest, abdomen, and pelvis
  • MRI chest
  • octreotide scanning
  • gallium-68 DOTATATE PET/CT
More investigations to consider

Treatment algorithm


Cushing disease (adrenocorticotropic hormone [ACTH]-secreting pituitary tumor)

ectopic ACTH or corticotropin-releasing hormone (CRH) syndrome

ACTH-independent due to unilateral adrenal carcinoma or adenoma

ACTH-independent due to bilateral adrenal disease (hyperplasia or adenoma)



Maria Fleseriu, MD, FACE

Professor of Medicine (Endocrinology) and Neurological Surgery


Pituitary Center

Oregon Health & Science University




MF is on the Pituitary Society's Board of Directors. She holds a research grant to the University for Clinical Studies as Principal Investigator for Recordati and Strongbridge, and is an occasional Scientific Consultant for Recordati, HRA Pharma, and Sparrow. MF is an author of several references cited in this topic.


Dr Maria Fleseriu would like to gratefully acknowledge Dr Ty Carroll and Dr James Findling, previous contributors to this topic.


TC is an author of a number of references cited in this topic. He is an investigator in clinical trials sponsored by Corcept. JF is an author of a number of references cited in this topic. He is a consultant for, and investigator in, clinical trials sponsored by Corcept and Novartis.

Peer reviewers

Paul M. Stewart, FRCP FMedSci

Professor of Medicine

Director of Research

College of Medical and Dental Sciences

University of Birmingham

Honorary Consultant Physician

Queen Elizabeth Hospital




PMS declares that he has no competing interests.

Antoine Tabarin, MD


Department of Endocrinology

University Hospital of Bordeaux




AT declares that he has no competing interests.

Liliana Contrersas, MD


Endocrine Research Department

Instituto de Investigaciones Médicas A. Lanari

University of Buenos Aires and IDIM-CONICET

Buenos Aires



LC declares that she has no competing interests.

Philip R. Orlander, MD

Professor of Medicine


Division of Endocrinology, Diabetes & Metabolism

University of Texas Medical School




PRO declares that he has no competing interests.

Mouhammed Amir Habra, MD, FACP, FACE

Assistant Professor

Department of Endocrine Neoplasia and Hormonal Disorders

Division of Internal Medicine

University of Texas MD Anderson Cancer Center




MAH declares that he has no competing interests.

  • Cushing syndrome images
  • Differentials

    • Obesity
    • Metabolic syndrome
    More Differentials
  • Guidelines

    • Diagnosis, management, and followup of the incidentally discovered adrenal mass
    • American Association of Endocrine Surgeons guidelines for adrenalectomy
    More Guidelines
  • Patient leaflets

    Cushing syndrome caused by an internal problem

    Cushing syndrome caused by medication

    More Patient leaflets
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer