What are the Symptoms of High Cortisol (AHC)?
Severe AHC (overt adrenal Cushing syndrome) causes many symptoms including weight gain, increased fat deposition in the face and back, easy bruising, thin skin, stretch marks on the skin, and depression. Most patients with AHC, however, have mild or moderate disease and do not have this classic look. Their symptoms are subtler and easily blamed on age, stress or lifestyle: gradual weight gain, high blood pressure, rising blood sugar, thinning bones, fatigue, poor sleep and low mood. Some patients with cortisol overproduction even feel “normal”, often because they have lived with the disease undiagnosed for years and have become used to how life now feels. Not having the classic Cushing look does not mean the cortisol is harmless.The Classic Symptoms of Cushing Syndrome (Severe AHC) Are:
High cortisol (severe AHC, or Cushing syndrome) causes many symptoms throughout the body.
- Weight gain with central obesity (meaning unusual fat deposition around your abdomen)
- Facial rounding and plethora (called moon face)
- Supraclavicular and dorsocervical fat pads (fat deposits on the back; “buffalo hump”)
- Easy bruising, thin skin
- Poor wound healing
- Purple striae (stretch marks, especially on the lower abdomen and upper thighs)
- Proximal muscle weakness
- Emotional and neurocognitive changes (Variable, but may be: anxiety, depression, memory problems, etc)
- Opportunistic and fungal infections (in severe disease)
- Acne and hirsutism (excessive facial hair). These are uncommon with a benign cortisol-producing adrenal tumor; when they are marked, other causes, including adrenocortical carcinoma, need to be considered
Symptoms of Mild and Moderate AHC (formerly MACS or Subclinical Cushing Syndrome)
Most people with AHC never develop a moon face or purple stretch marks. Instead, the excess cortisol shows up as common health problems that are harder to control than expected, or that appear earlier in life than expected:
- High blood pressure, especially when it starts early or needs several medications
- Prediabetes or type 2 diabetes, or diabetes that is becoming harder to control
- Gradual weight gain, mostly around the abdomen
- Osteoporosis and fractures. Fractures of the spine can occur even when a bone-density scan looks acceptable
- High cholesterol and cardiovascular disease (heart attack, stroke)
- Fatigue and poor sleep
- Low mood, anxiety, and trouble with memory or concentration
None of these is specific to AHC, which is why the disease is so often missed. If you have an adrenal nodule (adenoma) and one or more of these problems, you should be tested for cortisol excess. AHC is more common in women than in men.
What health problems does high cortisol cause that your doctor can find on an exam or laboratory tests?
- Hypertension (high blood pressure)
- Osteopenia and osteoporosis (weak bones)
- Fragility fractures, including fractures of the spine
- Fasting hyperglycemia (high blood sugar)
- Diabetes mellitus
- Hypokalemia (low blood potassium), mainly in severe disease
- Hyperlipidemia (high blood fats such as cholesterol)
- Leukocytosis (high white blood cell count)
What is Mild AHC (MACS, Subclinical Cushing Syndrome)?
Overt Cushing syndrome (meaning the signs and symptoms are obvious on examination) is relatively rare, with only a few new cases per million people per year. However, milder overproduction of cortisol by an adrenal tumor is very common. It used to be called “subclinical hypercortisolism”, “subclinical Cushing syndrome” or MACS; we now call it mild or moderate AHC.- Mild AHC is not harmless. It is linked to high blood pressure, diabetes, fractures, cardiovascular disease and a higher risk of early death. The word “subclinical” has been abandoned because the condition is not clinically silent.
- The diagnosis is often overlooked because the signs are subtle and the right test is not ordered. At the Carling Adrenal Center we evaluate patients with AHC every day, and we can often arrive at the correct diagnosis very quickly.
- Most patients present with an “adrenal incidentaloma”: an adrenal tumor seen on a CT or MRI scan done for other reasons. The work-up is then a simple blood test, the 1-mg overnight dexamethasone suppression test, together with ACTH and DHEA-S. A 24-hour urine cortisol is usually normal in mild and moderate AHC, so a normal result does not rule it out.
- Adrenalectomy is the only cure. In mild AHC the decision for surgery is individualized, based on your cortisol-related health problems (such as high blood pressure, diabetes or prediabetes, osteoporosis and weight gain), whether one or both glands are involved, your age, surgical risk and your preference.
Will my symptoms improve after treatment for mild and moderate AHC?
Removing the tumor (adrenalectomy) is the only way to cure AHC. A randomized trial (CHIRACIC, published in Lancet Diabetes & Endocrinology in 2025) found that adrenalectomy improved blood pressure control compared with conservative care: the blood pressure goal was met in 46% of operated patients, compared with 15% of those managed without surgery. Blood sugar, body weight and cholesterol also improve in many patients, although the study results for these are less consistent. Not every patient with an abnormal test needs an operation, but in our view surgery is underused in AHC, and simply watching should not be the automatic choice. Read more about adrenalectomy for AHC, including the role of cortisol-lowering medication, and about the trial in our blog post on surgery and high blood pressure. Click here to read more about how AHC and Cushing Syndrome are diagnosed, as the diagnosis is often overlooked, even in obvious disease. Because the signs of mild AHC are subtle, blood tests and a CT scan are crucial in establishing the diagnosis.Last updated October 2026.