Signs and Symptoms of Cushing's Disease in Women
Women with Cushing's disease present with a characteristic constellation of physical findings including central obesity with supraclavicular and dorsocervical fat accumulation, wide purple striae (>1 cm), proximal muscle weakness, facial plethora, and menstrual irregularities with hirsutism. 1, 2
Cardinal Physical Examination Findings
Fat Distribution Abnormalities
- Central obesity with characteristic fat deposition in the supraclavicular fossae and temporal fossae 2, 3
- "Moon face" (rounded facial appearance with facial plethora) 2
- Buffalo hump (dorsocervical fat pad at the back of the neck) 1, 2
- Supraclavicular fat accumulation (highly specific finding) 1, 2
Skin and Integumentary Changes
- Wide purple/violaceous striae (>1 cm width, especially on the abdomen) - this is a highly specific finding 1, 2, 3
- Facial plethora (reddish-purple facial appearance) 1, 2
- Easy bruising and ecchymoses (thinned skin) 1, 3
- Acne 1, 2
Musculoskeletal Manifestations
- Proximal muscle weakness or wasting, particularly in the lower limbs and shoulder girdle 1, 2, 3
- Fragility fractures (due to osteoporosis from chronic hypercortisolism) 1
Female-Specific Features
- Menstrual irregularities (oligomenorrhea or amenorrhea) 1
- Hirsutism (excessive hair growth in male-pattern distribution) 1, 2
- Virilization in severe cases 1
Associated Systemic Manifestations
Cardiovascular and Metabolic
- Severe hypertension (often difficult to control) 1, 2
- Diabetes mellitus or glucose intolerance 1, 3
- Fluid retention 1
Neuropsychiatric Symptoms
Other Clinical Features
- Weight gain with continued weight gain despite attempts at weight loss 1, 3
- Increased susceptibility to infections (due to immunosuppression) 3, 4
Clinical Diagnostic Approach
The combination of central obesity, moon face, dorsocervical fat pad, and wide purple striae has high specificity for Cushing's syndrome and should prompt immediate biochemical screening. 2
Key Discriminating Features
The most specific clinical features that distinguish Cushing's disease from simple obesity or other conditions include: 3, 5
- Abnormal fat distribution in supraclavicular and temporal fossae
- Proximal muscle weakness
- Wide purple striae (>1 cm)
- Facial plethora with thinned skin
Important Clinical Pitfall
Not all women with Cushing's disease present with obesity - some may have normal weight but demonstrate the characteristic fat redistribution pattern. 1 The absence of striae does not rule out Cushing's disease, as diagnostic emphasis should be on the overall constellation of findings. 2
When to Screen
All patients with adrenal incidentalomas require screening for autonomous cortisol secretion regardless of symptoms. 1 For symptomatic patients, biochemical confirmation is mandatory using the 1 mg dexamethasone suppression test (preferred), 24-hour urinary free cortisol, or late-night salivary cortisol. 1, 3, 4