dromlakhani Assess for Cushing syndrome, thyroid dysfunction, acromegaly, or hyperprolactinemia if clinical features are present
STEP 1 — Gather Information
Obtain targeted history and physical exam for features of Cushing (weight gain, proximal weakness, purple striae, easy bruising), thyroid dysfunction (fatigue, cold intolerance, weight gain, dry skin, hair loss), acromegaly (enlarged hands/feet, coarse facial features, jaw protrusion, spaced teeth), and hyperprolactinemia (galactorrhea, menstrual irregularities, decreased libido, infertility). Order baseline labs if any feature is present: TSH, free T4, prolactin, IGF-1, and morning cortisol or late-night salivary cortisol as indicated.
STEP 2 — Rule In / Rule Out
Are any specific clinical features of Cushing syndrome, thyroid dysfunction, acromegaly, or hyperprolactinemia present? If yes, proceed to targeted testing (Step 3). If no, rule out these uncommon causes and continue routine hirsutism evaluation.
STEP 3 — Classify or Stratify
Match the presenting feature to the appropriate test: Cushingoid features → late‑night salivary cortisol or 1‑mg overnight dexamethasone suppression test; hypothyroid signs → TSH and free T4; acromegalic changes → IGF‑1; galactorrhea/menstrual disturbance → serum prolactin (consider macroprolactin if discordant). Perform the selected test(s).
STEP 4 — Decide
If the targeted test is abnormal, refer to endocrinology for further evaluation and disease‑specific management. If all tests are normal, attribute hirsutism to more common etiologies (e.g., PCOS, idiopathic) and follow standard hirsutism management pathways.
Clinical Guardrails / Mimics / Pitfalls
Do not screen for these disorders in the absence of suggestive clinical features due to low yield and risk of false‑positives. Beware of assay pitfalls: stress‑induced cortisol elevation, macroprolactin causing spurious prolactin elevation, and IGF‑1 variability with age/puberty. Obesity can mimic Cushing; avoid attributing weight‑related striae to Cushing without biochemical confirmation. Medications (e.g., antipsychotics, antihypertensives) can raise prolactin—review drug history before pursuing pituitary imaging.
Concrete Clinical Example
A 28‑year‑old woman presents with hirsutism, oligomenorrhea, and galactorrhea. Physical exam shows no Cushingoid or acromegalic features, but she reports fatigue and dry skin. Prolactin is 85 ng/mL (elevated); TSH and free T4 are normal. She is referred to endocrinology for pituitary MRI to evaluate a prolactinoma.
Source: Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2018, DOI:10.1210/jc.2018-00241