Cortisol is the the king of all hormones. Ideally, I would have started discussing cortisol at the beginning of our hormone series, since it is at the top of the hormone hierarchy. However, most people focus on the third level of hormones, the sex hormones. So let’s set up our discussion by putting all of these hormones in perspective. At the top of the hormone hierarchy, cortisol is number one, then thyroid hormone, and insulin, followed by all of the other hormones we’ve discussed.
Today I’ll introduce cortisol and talk about why it’s so important, testing for cortisol imbalances, relative cortisol deficiency, and the treatment for low cortisol.
What Does Cortisol Do?
Cortisol is essential. You would die quickly without cortisol; it is literally necessary for survival.
Cortisol has many varied, important functions in your body, including:
- Regulating bone density and metabolism
- Controlling the stress response
- Regulating the immune system
- Suppressing inflammation
- Regulating sleep and wakefulness
- Helping to balance other hormones
- Managing glucose
It’s very important – and necessary – to produce more cortisol when you’re stressed, but chronically elevated cortisol can be harmful to the body. Ideally, we would not spend much of our lives in a stressed state. However, if we live a chronically stressed life – whether it’s physical stress, emotional stress, or environmental stress – over time, this drains the brain’s ability to respond and results in low cortisol.
To determine if you have a relative cortisol excess or deficiency, you need to do some form of cortisol testing. The ideal test for cortisol is a salivary cortisol level test that you can do at home, which checks levels throughout the day and night to see how your cortisol is fluctuating. Blood testing, typically done either first thing in the morning or in the evening, is done by an endocrinologist or someone who specializes in hormones in order to diagnose Addison’s disease or Cushing’s disease. This is sometimes a first screening test to look for a cortisol issue, but if this is normal, then a deeper dive into salivary testing may be ordered. Solid rate testing is not the ideal way to diagnose Addison’s or Cushing’s unless the levels are super high or super low.
Relative Cortisol Deficiency
Today we’re going to discuss relative cortisol deficiency, or hypocortisolism, often referred to as adrenal fatigue. The adrenal glands do not actually fatigue, they keep on working. Insufficient cortisol is produced because of an issue with the hypothalamus, which communicates with the pituitary, which then communicates with the adrenal glands. We call this HPA (hypothalamus, pituitary, adrenal) axis dysregulation. This is a brain issue, not actually an adrenal problem. So when we hear the term adrenal fatigue or hypocortisolism, it’s generally a brain-based issue.
This is a key concept: When you see cortisol issues, think that something is stressing the brain.
The exceptions are Addison’s disease or Cushing’s disease, but both of these are quite rare. Excess cortisol production from tumors or other cortisol-secreting glands is called Cushing’s disease. This is typically caused by cortisol or ACTH-producing tumors. Addison’s disease is the exact opposite when the adrenals stop making cortisol. This is usually due to an autoimmune process. We’re not going to discuss these today as they are out of the scope of our discussion of relative cortisol imbalances.
Causes of Cortisol Deficiency
So what kind of things can stress the brain and cause the adrenal glands to not produce enough cortisol?
These are a few causes of low cortisol:
- Excessive alcohol
- Drug exposure
- Gut dysbiosis
- Chronic infections
- Immune issues
- Dental infections
- Chronic Lyme disease
- Reactions to mold exposure
- The most common cause in America: Long-term, unmitigated stress
Chronic stress can include physical, emotional, or environmental stress, for example, stress from your job, stress from sleep apnea, stress from toxic relationships, or toxins in the environment.
These issues can result in cortisol deficiency because of the effect on the brain, and can also lead to chronic pain, poor sleep hygiene, depression, and similar symptoms of so-called adrenal fatigue.
Symptoms of Relative Cortisol Deficiency (HPA Axis Dysregulation)
These symptoms will sound familiar if you’ve been reading our blog series on hormones:
- Allergy symptoms
- Decreased immunity
- Low libido
- Gut issues
- Digestive problems
- Increased tendency to look for stimulation through alcohol, drugs, Adderall, caffeine, etc.
- Feelings of overwhelm
- Low glucose issues (hypoglycemia)
- Premenstrual syndrome (PMS)
- Perimenopausal symptoms
- Decreased stamina
- Lack of motivation
- Low blood pressure
- Poor healing
- Unresponsive thyroid
So it’s really easy to see how low cortisol can be mistaken for low estrogen or other low hormone levels when it’s actually primarily a cortisol issue.
Diseases affected by cortisol
There are a number of diseases that are affected by cortisol dysregulation, including:
- Polycystic ovarian syndrome (PCOS)
- Breast cancer
- Chronic fatigue syndrome
- Heart disease
- Multiple sclerosis
- Irritable Bowel Syndrome
- IBS menopause
- Male low testosterone (known as andropause)
- Osteoporosis or osteopenia
- Post-traumatic stress disorder (PTSD)
- Rheumatoid arthritis
- Sleep disorders
All of these can be exacerbated by cortisol that is too high or too low. Addressing imbalanced cortisol levels can often help reduce the symptoms of these diseases. And perhaps the root cause of some of these or many of these could be primarily a cortisol issue.
Addressing Low Cortisol
How do we address low cortisol therapeutically?
First, we look for the root cause.
Obviously, treating the HPA brain axis issue is important, but finding the root cause is always the primary goal. Working with a practitioner can be super helpful in determining the root cause, which could be:
- Undiagnosed sleep apnea
- Nutritional deficiencies
- Gut issues
- Environmental toxins
- Mold in the environment
- Chronic infections (e.g. Lyme)
Nutrients that can help include:
- Vitamin C (most important for low cortisol)
- B vitamins
As we think about nutrients, especially vitamin C, it is interesting to consider the Native American populations who used to use elk adrenals as their source of vitamin C to make it through the winter. They didn’t have citrus. There were no limes or oranges in Canada and Alaska. But First Nation groups had been living there for a long time without scurvy because they figured out that animal adrenals are high in vitamin C!
Stress reduction needs to be a priority.
Stress reduction is a key component in cortisol dysfunction and is probably the most difficult thing to address. Meditation, prayer, time spent in nature, regular gentle exercise, yoga, time spent with loved ones and/or pets, reprioritizing work or relationship demands, more focus on time management, removing toxic relationships, time spent in the flow state, and positive social interaction are just a few things to consider as a starting point.
Adaptogenic herbs can help your body better respond to stress.
As we are addressing the root cause of a cortisol imbalance, I really like adaptogenic herbs because they do just that – they help your body adapt. If your cortisol is balanced, adaptogens don’t affect cortisol much. If it’s elevated, they tend to bring it down. If it’s low, they tend to bring it up. adaptogenic herbs were actually used by Russian athletes in the 1960s and 70s to increase their exercise resilience and improve performance. Adaptogens include ashwagandha, Panax ginseng, Rhodiola rosea, and cordyceps sinensis. For stress symptoms, calming herbs can also be used.
Other ways to address low cortisol:
If cortisol levels are really low, adrenal extracts or licorice might be considered. I tend to recommend this under the supervision of a practitioner after testing is done, because these will actually boost cortisol, can increase blood pressure, and could cause other medical issues. Adrenal extracts and licorice should only be used for low cortisol under the supervision of a licensed healthcare practitioner.
Finally, another way to treat low cortisol is to use Cortef hydrocortisone. Personally, I never do this, and instead I would refer the person to an endocrinologist. If the patient needs hydrocortisone treatment, they could likely have Addison’s disease, which puts them at a greater risk from inadequate cortisol support.
In my clinic, patients with relative cortisol deficiency have had good results with the other treatments above in raising their cortisol levels and I have not personally had to start patients on Cortef hydrocortisone. I do see many people who are already taking Cortef, but usually, I help them wean off of it because they don’t have true Addison’s disease, but instead have a severe HPA Axis dysfunction or a brain-based issue.
Next week on the blog, I’ll talk about elevated cortisol, also known as stage 1 and stage 2 adrenal dysfunction, which I counter more often in my clinic.
If you’d like to learn more about your hormones, check out the recommended reading list on our website, as well as our other blog articles in this series. Follow us on social media to keep up to date with what we’re doing, our education materials, as well as our podcasts. If you’d like to be part of our newsletter, sign up on the website, and you’ll get the updates routinely.
Take care and be well.
Since 2010, Richmond Integrative and Functional Medicine has been helping people to restore their health and hope with an integrative approach to conventional and alternative medicine that’s entirely science-backed. We at RIFM believe everyone is made for health. We offer a comprehensive, in-person patient membership program to ensure you get access to the care you need to thrive.
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