In the introduction to this series, I outlined the hormone hierarchy. At the top of the hierarchy is cortisol: the King of All Hormones. Cortisol is absolutely essential for life. You would die quickly without cortisol; it is literally necessary for survival.
Cortisol helps your body mount a quick, energetic reaction to stress, whether it’s evading immediate danger or tackling a demanding task. However, it’s a hormone that prefers balance — not too high … not too low. Excess cortisol over prolonged periods can lead to health troubles like depression, anxiety, and chronic fatigue, while too little can manifest as low energy, weakened immunity, and difficulty handling stress. In functional medicine, we aim for the “Goldilocks zone” where cortisol levels are just right, ensuring optimal health and wellbeing.
In this article, I’ll address both cortisol imbalances (too low and too high) looking at symptoms, causes, and solutions for addressing both imbalances. I’ll also discuss testing to figure out if you are struggling with an imbalance.
But first, let’s quickly look at what cortisol is and what it does.
Understanding “The King”
Cortisol is a lipid-based hormone (it’s actually made from cholesterol) produced by your adrenal glands perched atop your kidneys. It plays an instrumental role in a variety of bodily functions, from regulating your body’s stress response and metabolism of glucose, to managing blood pressure, reducing inflammation, and aiding in the immune system’s response.
When it becomes unbalanced, dysregulated cortisol can lead to a number of diseases.
Diseases Affected by Cortisol
There are a number of diseases that are affected by cortisol dysregulation. All of these can be exacerbated by cortisol that is either too high or too low, and the root cause of many of these could be primarily a cortisol issue.
- Breast Cancer
- Chronic Fatigue Syndrome
- Heart Disease
- Irritable Bowel Syndrome (IBS)
- Male low testosterone (known as andropause)
- Multiple Sclerosis
- Osteoporosis or Osteopenia
- Polycystic Ovarian Syndrome (PCOS)
- Post-Traumatic Stress Disorder (PTSD)
- Rheumatoid arthritis
- Sleep disorders
“Relative Cortisol Deficiency” • “Hypercortisolism” • “Adrenal Fatigue”
Relative cortisol deficiency, or hypocortisolism, is often called “adrenal fatigue.” However, the adrenal glands don’t actually fatigue; they keep on working. Insufficient cortisol results from an issue with the hypothalamus, which communicates with the pituitary gland, which then communicates with the adrenal glands.
Cortisol Deficiency is a dysregulation of the HPA Axis (Hypothalamus • Pituitary • Adrenal). Low cortisol is actually a brain issue, not an adrenal problem. So when we hear the term adrenal fatigue or hypocortisolism, it’s generally a brain-based issue.
When we hear the term adrenal fatigue or hypocortisolism, it’s generally a brain-based issue.
The exceptions are Addison’s Disease (too low) or Cushing’s disease (too high), but both of these are extreme edge cases and quite rare. If you suspect a cortisol imbalance and follow my advice to Test: Don’t Guess… you needn’t worry about missing the rare edge cases.
This is a key concept: When you see cortisol issues, something is stressing the brain.
Symptoms of Cortisol Deficiency
- Allergy symptoms
- Decreased immunity
- Decreased stamina
- Digestive problems
- Feelings of overwhelm
- Gut issues
- Increased tendency to look for stimulation through alcohol, drugs, Adderall, caffeine, etc.
- Lack of motivation
- Low blood pressure
- Low glucose issues (hypoglycemia)
- Low libido
- Perimenopausal symptoms
- Poor healing
- Premenstrual syndrome (PMS)
- Unresponsive thyroid
Remember the hormone hierarchy? You can see from this list how easy it would be to mistake a cortisol issue for low estrogen or testosterone. But we need to address the top of the hierarchy first!
Causes of Cortisol Deficiency
- Chronic Lyme disease
- Chronic Stress
- Chronic infections
- Dental infections
- Drug exposure
- Excessive alcohol
- Gut dysbiosis
- Immune issues
- Reactions to mold exposure
- Sleep Apnea
Remember: When you see cortisol issues, something is stressing the brain. So, what kinds of things stress the brain and cause the adrenal glands to not produce enough cortisol? The most common cause in America: Long-term, unmitigated stress.
The most common cause in America: Long-term, unmitigated stress.
Chronic stress can include physical, emotional, or environmental stress (e.g. stress from your job, stress from sleep apnea, stress from toxic relationships, or toxins in the environment). The effect of stress on your brain can lead to cortisol deficiency, which can then lead to chronic pain, poor sleep hygiene, depression, and similar symptoms of so-called adrenal fatigue.
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.
Addressing Cortisol Deficiency
How do we address low cortisol therapeutically?
First: Look for the Root Cause
While treating the HPA Axis issue is important, finding (and addressing) the root cause should always be the primary goal. From the longer list of causes above, there’s a short-list of potential “root causes” we need to look for:
- Undiagnosed Sleep Apnea
- Nutritional Deficiencies
- Gut Issues
- Environmental Toxins
- Mold Exposure
- Chronic Infections
Prioritize Stress Reduction
Stress reduction is critical 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.
For more specific strategies, consider my four-part series, “Lifestyle Medicine for Stress.”
Consider Adaptogenic Herbs
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.
A few adaptogens I recommend for you to consider:
For stress symptoms, calming herbs can also be used.
Restore & Reinforce Your Nutrients
The following nutrients are critical for proper cortisol production, and should be considered to address a cortisol deficiency:
- B Vitamins
- Vitamin C** (The most important nutrient for low cortisol)
Did you know?…
Many Native American populations depended on 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!
Some Additional Strategies for Addressing Low Cortisol:
Adrenal extracts & licorice: If cortisol levels are really low, adrenal extracts or licorice might be considered. However, I only recommend these interventions under the supervision of a practitioner after testing Adrenal extracts and licorice will actually boost cortisol, can increase blood pressure, and could cause other medical issues.
Cortef hydrocortisone: Finally, another way to treat low cortisol is to use Cortef hydrocortisone. However, if a patient needs hydrocortisone treatment, they could be one of the rare cases with Addison’s disease, which puts them at a greater risk from inadequate cortisol support. In these rare cases, I would refer the person to an endocrinologist. In my clinic, patients with relative cortisol deficiency have had good results with the other treatments above, and I have not personally needed to start patients on Cortef hydrocortisone. I do see many people who are already taking Cortef, but I usually help to wean them 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.
As noted at the outset, it’s also possible to have too much cortisol…
“Hypercortisolism” • “Stage 1 Adrenal Fatigue”
How do you know if you have excessive cortisol?
Symptoms of Elevated Cortisol
- Abnormal cholesterol
- Binge eating
- Compromised immune system
- Elevated blood sugar levels
- Elevated triglycerides
- Hypertension (high blood pressure)
- Insulin resistance
- Muscle weakness
- Night sweats
- Sleep disturbances
- Thyroid symptoms (impaired conversion from T4 to T3)
Does this list of symptoms sound like someone you know? Of course it does. You could use this list to describe the typical stressed American.
Low-grade hypercortisolism is rampant in our current culture, and this is setting us up for a multitude of illnesses and diseases. This is why I believe that managing stress – whether personal or environmental – needs to be a priority for all of us because stress affects the king of all hormones, cortisol, and then proceeds to affect all of our hormones downstream.
It might surprise you to see fatigue in a list of symptoms of elevated cortisol. But after having chronically elevated cortisol, we often see fatigue develop. Elevated cortisol can also cause rising glucose levels and thyroid dysfunction. This is also the reason why I call cortisol the king of all hormones, because an excess can affect the other two important hormones in the hormonal hierarchy (insulin and thyroid) and cause a cascade of effects downstream.
Addressing Excess Cortisol
Nutrients & Adaptogenic Herbs: As with low cortisol, there are specific nutrients your body needs to balance cortisol effectively. Some of these nutrients are vitamin C, B vitamins, calcium, magnesium, zinc, copper, selenium, and manganese. There are also many helpful adaptogenic herbs noted above such as: Ashwagandha, Panax Ginseng, Rhodiola Rosea, and Cordyceps Sinensis.
By far, the most important factor in managing elevated cortisol is stress reduction. This can be in the form of managing: physical stress from an inflammatory diet or gut issues; mental stress from toxic relationships, unreasonable expectations, or poor time management; or environmental stress from toxic chemicals, mold, or other toxins in our environment.
For more specific strategies, consider my four-part series, “Lifestyle Medicine for Stress.”
Test… Don’t Guess!
While you can take various supplements or adaptogenic herbs to support cortisol balance, the best thing to do first is just to get tested. That cuts through the confusion of these lists of symptoms, which can often sound alike.
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 administered 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.
It Helps to Have a Guide
It helps to see a practitioner who will create a timeline as part of your evaluation to figure out what started first. Was it your sugar issue first, then your thyroid, and then your cortisol? Or did the cortisol imbalance start first? Perhaps it started with nutritional deficiencies and then mold exposure from a building you lived in for 20 years. This is why learning about you and investigating your own health is profoundly important. This is also where functional medicine comes into play because functional medicine doesn’t just look at the symptoms. It also takes your environment and your history into consideration to help figure out the best way to address your issues.
Why Zebras Don’t Get Ulcers
The Acclaimed Guide to Stress, Stress-Related Diseases, and Coping
Robert Sapolsky PhD
With a mixture of whit and cutting-edge research, Dr. Sapolsky reveals how chronic stressors can change our bodies function and create an environment of mental illness and physical disease. Unlike Zebras, we can’t switch from a state of dread, being chased by a lion, and then moments later go back into a relation state and begin to graze again.