Cortisol

What It Is

Cortisol is often called the "stress hormone," but that label is misleading—cortisol is essential for survival. It's the body's primary adaptive hormone, designed to help you respond to challenges, maintain energy, regulate inflammation, and manage daily rhythms. The problem isn't cortisol itself—it's cortisol dysregulation, which becomes increasingly common during perimenopause and menopause.

Where it's produced:

• Adrenal glands → two small glands that sit on top of the kidneys
• Produced in response to signals from the hypothalamic-pituitary-adrenal (HPA) axis (the stress response system)

Primary functions:

• Regulates energy and metabolism → increases blood sugar (for fuel during stress), influences fat storage, affects insulin sensitivity
• Supports the stress response → helps you respond to acute challenges (physical, emotional, psychological)
• Regulates inflammation → cortisol is anti-inflammatory (which is why synthetic cortisol—prednisone—is used to treat inflammation)
• Maintains blood pressure → helps regulate fluid balance and vascular tone
• Supports immune function → modulates immune response (too much cortisol suppresses immunity; too little allows inflammation to run wild)
• Regulates circadian rhythm → cortisol rises in the morning (to wake you up) and declines at night (to allow sleep)
• Affects mood and cognition → influences memory, focus, emotional regulation, resilience

Cortisol is not the enemy—dysregulation is:

Healthy cortisol rhythm:

• Morning: Cortisol peaks 30-45 minutes after waking ("cortisol awakening response") → gives you energy and alertness
• Throughout the day: Cortisol gradually declines
• Evening: Cortisol is low → allows melatonin to rise, promoting sleep
• Response to stress: Cortisol rises briefly in response to a challenge, then returns to baseline

Dysregulated cortisol:

• Chronically elevated → cortisol stays high throughout the day (chronic stress, anxiety, insomnia)
• Blunted morning rise → cortisol doesn't peak in the morning → fatigue, difficulty waking, low energy
• High at night → cortisol remains elevated in the evening → difficulty falling asleep, wired-but-tired feeling
• Flattened curve → cortisol doesn't rise or fall appropriately → fatigue, low resilience, mood instability

During perimenopause, cortisol dysregulation becomes more common because the HPA axis (stress response system) is closely linked to the HPO axis (reproductive hormone system)—when one destabilizes, the other often follows.

Why It Matters During Perimenopause/Menopause

Cortisol and sex hormones (estrogen, progesterone, testosterone) are intricately connected—they're produced from the same starting material (cholesterol) and regulate each other via overlapping pathways. When sex hormones fluctuate or decline during perimenopause, cortisol regulation often becomes less efficient.

The pattern:

Early perimenopause:

• Estrogen and progesterone begin to fluctuate → HPA axis becomes more reactive
• Progesterone decline → loss of GABA-enhancing, calming effects → heightened stress response, elevated cortisol
• Estrogen fluctuations → estrogen helps regulate cortisol feedback loops; when estrogen swings, cortisol regulation becomes erratic
• Sleep disruption begins → sleep deprivation raises cortisol → cortisol elevation disrupts sleep → vicious cycle

Mid-perimenopause:

• Cortisol dysregulation intensifies → chronic stress, sleep deprivation, and hormonal chaos create a perfect storm
• Wired-but-tired pattern emerges → cortisol is high when it should be low (night), low when it should be high (morning)
• Stress resilience declines → small stressors feel overwhelming; recovery from stress takes longer
• Inflammation increases → chronic cortisol elevation initially suppresses inflammation, but over time the system becomes less responsive → inflammation rises

Late perimenopause and menopause:

• Cortisol patterns may stabilize for some women (as sex hormones stabilize at low levels)
• For others, HPA axis dysfunction persists → chronic fatigue, insomnia, low stress resilience, inflammation
• Adrenal health becomes critical → adrenals produce both cortisol and small amounts of sex hormones after menopause; if adrenals are exhausted, both cortisol and sex hormone production suffer

Why cortisol dysregulation matters so much:

1. It affects every system → cortisol receptors exist in nearly every cell; dysregulation impacts metabolism, immunity, mood, cognition, sleep, inflammation, cardiovascular health
2. It worsens other symptoms → cortisol dysregulation amplifies hot flashes, anxiety, insomnia, weight gain, brain fog
3. It creates a vicious cycle → stress raises cortisol → high cortisol disrupts sleep → poor sleep raises cortisol → cortisol suppresses sex hormones → low sex hormones worsen stress resilience → cycle continues
4. It's often overlooked → cortisol dysregulation is not routinely tested; symptoms are attributed to "stress" or "just menopause" rather than HPA axis dysfunction

The "pregnenolone steal" or "cortisol steal" myth:

You may have heard that chronic stress "steals" progesterone to make cortisol, worsening hormone imbalance. The reality is more nuanced:

• Progesterone and cortisol are both made from pregnenolone (which is made from cholesterol)
• Under chronic stress, the body prioritizes cortisol production (because survival demands it)
• This doesn't literally "steal" progesterone, but it can shift resources away from sex hormone production
• Result: Chronic stress can suppress ovulation → lower progesterone → worsening symptoms

The take-home: Chronic stress worsens hormonal imbalance, and managing stress is essential for hormonal health.

How It Works

Mechanism of action:

Cortisol is a steroid hormone (like estrogen, progesterone, testosterone). It works by:

1. Binding to cortisol receptors (glucocorticoid receptors, GR) in cells throughout the body
2. Entering the cell nucleus and affecting gene expression (turning genes on or off)
3. Producing effects over hours to days (cortisol is not a fast-acting hormone like adrenaline)

The HPA axis (stress response system):

1. Hypothalamus (brain) detects stress → releases CRH (corticotropin-releasing hormone)
2. Pituitary gland (brain) responds to CRH → releases ACTH (adrenocorticotropic hormone)
3. Adrenal glands respond to ACTH → produce and release cortisol
4. Cortisol feeds back to brain → tells hypothalamus and pituitary to reduce CRH and ACTH (negative feedback loop)
5. When stress ends, cortisol returns to baseline

In chronic stress or HPA axis dysfunction, this feedback loop breaks down:

• Brain becomes less sensitive to cortisol's feedback signals → cortisol stays elevated
• OR: Adrenals become less responsive to ACTH → cortisol production is blunted → fatigue, low resilience
• OR: Cortisol rhythm flattens → no clear morning peak or evening decline → sleep and energy are disrupted

Cortisol's relationship with other hormones:

Cortisol + Estrogen:

• Estrogen enhances cortisol-binding globulin (CBG), which binds cortisol and modulates its availability
• Estrogen also affects HPA axis sensitivity → when estrogen is optimal, stress response is more regulated; when estrogen fluctuates or declines, cortisol regulation becomes erratic
• Result: Estrogen fluctuations in perimenopause can destabilize cortisol rhythms

Cortisol + Progesterone:

• Progesterone has GABA-enhancing, calming effects that buffer the stress response
• Progesterone also competes with cortisol for receptors (both are steroid hormones)
• When progesterone declines (perimenopause), cortisol's effects are less buffered → heightened stress reactivity, anxiety, difficulty calming down

Cortisol + Testosterone:

• Chronic high cortisol can suppress testosterone production (stress takes priority)
• High cortisol also increases SHBG (sex hormone-binding globulin), which binds testosterone and reduces free testosterone
• Result: Chronic stress lowers testosterone → fatigue, low libido, reduced motivation

Cortisol + Thyroid hormones:

• Cortisol affects conversion of T4 to T3 (active thyroid hormone)
• High cortisol can reduce T3 production → hypothyroid symptoms (fatigue, weight gain, brain fog, cold intolerance)
• Result: Chronic stress can create "functional hypothyroidism" even if thyroid gland is healthy

Cortisol + Insulin:

• Cortisol raises blood sugar (to provide fuel during stress)
• Chronic high cortisol → chronic elevated blood sugar → insulin resistance → weight gain (especially abdominal fat), metabolic dysfunction, increased diabetes risk
• Result: Chronic stress and cortisol dysregulation worsen metabolic health during menopause

Cortisol + Melatonin (sleep hormone):

• Cortisol and melatonin have opposing rhythms → cortisol rises in the morning, melatonin rises at night
• When cortisol is high at night, melatonin can't rise → difficulty falling asleep, non-restorative sleep
• Poor sleep raises cortisol → vicious cycle

What It Looks Like

When Optimal (Healthy Cortisol Rhythm)

Physical:

• Wake feeling refreshed → cortisol peaks in the morning, giving you energy and alertness
• Stable energy throughout the day → cortisol gradually declines but remains adequate
• Fall asleep easily → cortisol is low at night, allowing melatonin to rise
• Healthy metabolism → blood sugar is stable, insulin sensitivity is good, weight is manageable
• Resilient immune system → cortisol modulates inflammation appropriately

Cognitive:

• Clear thinking, good focus → cortisol supports cognitive function (at optimal levels)
• Good memory → cortisol enhances memory consolidation (at moderate levels)
• Calm under pressure → able to handle stress without spiraling

Emotional:

• Resilient to stress → can respond to challenges and recover quickly
• Stable mood → cortisol is balanced, not too high or too low
• Calm in the evening → able to wind down, relax, transition to sleep

When Dysregulated: Chronically High Cortisol

Physical:

• "Wired-but-tired" feeling → exhausted but can't relax or sleep
• Insomnia → difficulty falling asleep, waking at 3-4 AM, non-restorative sleep
• Weight gain (especially abdominal) → cortisol promotes fat storage in the midsection, increases insulin resistance
• Blood sugar dysregulation → cravings for sugar/carbs, energy crashes, insulin resistance
• High blood pressure → cortisol affects vascular tone and fluid balance
• Digestive issues → cortisol affects gut motility, stomach acid, gut lining (IBS, reflux, bloating)
• Muscle loss → chronic high cortisol is catabolic (breaks down muscle for fuel)
• Bone loss → cortisol inhibits bone formation, accelerates osteoporosis
• Frequent infections → chronic high cortisol suppresses immune function
• Skin issues → acne, thinning skin, slow wound healing

Cognitive:

• Brain fog → difficulty concentrating, slower thinking
• Memory problems → chronic high cortisol damages the hippocampus (memory center)
• Overwhelm → everything feels like too much, difficulty prioritizing

Emotional:

• Anxiety → constant worry, restlessness, sense of dread
• Irritability, short fuse → low tolerance for frustration or demands
• Difficulty calming down → can't relax, always "on edge"
• Mood swings → emotional volatility, reactivity
• Reduced stress resilience → small stressors feel overwhelming

When Dysregulated: Low or Blunted Cortisol

This pattern is sometimes called "adrenal fatigue" or "HPA axis dysfunction":

Physical:

• Extreme fatigue → difficulty waking in the morning, exhaustion throughout the day
• No energy for exercise → feel worse after exertion, long recovery time
• Low blood pressure, dizziness → especially upon standing (orthostatic hypotension)
• Salt cravings → cortisol helps regulate sodium; low cortisol → crave salt
• Hypoglycemia → low blood sugar, shakiness, difficulty going long periods without eating
• Frequent infections → immune system is dysregulated (not enough cortisol to modulate inflammation)

Cognitive:

• Severe brain fog → difficulty thinking, processing information, making decisions
• Poor stress tolerance → even small tasks feel overwhelming

Emotional:

• Depression → low mood, low motivation, hopelessness
• Emotional flatness → difficulty feeling joy or excitement
• Overwhelm → life feels unmanageable, difficulty coping

Note: "Adrenal fatigue" is a controversial term (not recognized by conventional endocrinology), but HPA axis dysfunction is real—the issue is not that adrenals are "fatigued," but that the feedback loop between brain and adrenals is dysregulated.

When Dysregulated: Reversed Cortisol Rhythm

Cortisol is low in the morning, high at night:

Physical:

• Difficulty waking → no energy in the morning, hit snooze repeatedly
• Fatigue all day → energy is low until evening
• "Second wind" at night → suddenly feel wired, alert, energized at 9-10 PM
• Insomnia → can't fall asleep, mind races, body feels restless

Emotional:

• Anxiety at night → worries intensify in the evening
• Irritability → low tolerance in the evening (when cortisol should be low and calming)

Phase Impact

Baseline (Regular Cycle, Pre-Perimenopause): Cortisol rhythm is typically well-regulated. Estrogen and progesterone are stable, supporting healthy HPA axis function. Stress response is adaptive—cortisol rises in response to challenges and returns to baseline. Women may experience stress, but resilience is generally good.

Electric Cougar (Early Perimenopause): Progesterone declines → loss of calming, GABA-enhancing effects → HPA axis becomes more reactive. Cortisol may begin to run high, especially at night (contributing to insomnia). Estrogen surges can create periods of heightened energy (cortisol + estrogen), followed by crashes. The wired-but-tired pattern may begin here. Stress resilience starts to decline—small stressors feel bigger.

Wild Tide (Mid-Perimenopause): Cortisol dysregulation intensifies. Erratic estrogen and low progesterone destabilize the HPA axis. Sleep deprivation from night sweats and hormonal insomnia elevates cortisol → cortisol elevation worsens sleep → vicious cycle. Anxiety is often severe. The patience gap narrows—stress tolerance is low. Weight gain (especially abdominal) may accelerate due to cortisol-driven insulin resistance and fat storage.

Henapause (Late Perimenopause, 7-11 Months Without Period): Cortisol patterns may begin to stabilize for some women (as estrogen/progesterone fluctuations calm), but for others, chronic HPA axis dysfunction persists. Wired-but-tired is common. Insomnia may be severe. Inflammation increases (cortisol's anti-inflammatory effects are blunted). Adrenal health becomes critical—if adrenals are exhausted, fatigue is profound.

The Pause (Menopause, 12+ Months Without Period): Hormones stabilize at low levels → for many women, cortisol regulation improves. Sleep improves, anxiety decreases, stress resilience returns (though not to pre-perimenopause levels). For others, HPA axis dysfunction persists—chronic fatigue, insomnia, low resilience continue. Adrenal support (stress management, sleep, nutrition) is essential.

Phoenix Phase (Early Post-Menopause, 2-10 Years After Last Period): Cortisol rhythm has often stabilized. Women who have addressed stress, sleep, and lifestyle feel resilient and well. Those who haven't may continue to struggle with fatigue, insomnia, or low stress tolerance. HRT (especially progesterone) can help regulate cortisol. Adrenal health remains important (adrenals produce cortisol and small amounts of sex hormones).

Golden Sovereignty (Established Post-Menopause, 7+ Years After Last Period): Cortisol regulation is generally stable for most women. Chronic stress, poor sleep, or medical issues can still disrupt cortisol. Maintaining healthy cortisol rhythm supports longevity, cognitive health, metabolic health, and quality of life.

Testing & Optimization

When to Test

Testing cortisol can be helpful if you suspect dysregulation:

When testing makes sense:

• Chronic fatigue, especially if worse in the morning
• Insomnia (especially difficulty falling asleep or waking at 3-4 AM)
• Severe anxiety or "wired-but-tired" feeling
• Weight gain (especially abdominal) despite healthy diet and exercise
• Low stress resilience (everything feels overwhelming)
• Symptoms of low cortisol (dizziness, salt cravings, low blood pressure, extreme fatigue)

What tests measure:

Serum cortisol (blood test):

• Measures cortisol at a single point in time (usually 8 AM)
• Useful for diagnosing Cushing's syndrome (very high cortisol) or Addison's disease (very low cortisol)
• Not useful for assessing cortisol rhythm or mild HPA axis dysfunction

24-hour urinary free cortisol:

• Measures total cortisol output over 24 hours
• Useful for diagnosing Cushing's syndrome
• Doesn't show cortisol rhythm

Salivary cortisol (4-point test):

• Most useful for assessing cortisol rhythm
• Measures cortisol at 4 times during the day: morning (upon waking), noon, late afternoon, bedtime
• Shows whether cortisol peaks in the morning, declines throughout the day, and is low at night
• This is the test most functional/integrative practitioners use for HPA axis dysfunction
• Not covered by most insurance; often $150-300 out of pocket

ACTH stimulation test:

• Used to diagnose Addison's disease (adrenal insufficiency)
• Rarely needed unless cortisol is extremely low

When testing is tricky:

• Cortisol varies with stress, sleep, meals, exercise → difficult to interpret
• "Normal" ranges are wide and may not reflect optimal function
• Symptoms matter more than numbers
• Functional/integrative practitioners use salivary cortisol; conventional endocrinologists often don't

Optimization Strategies

1. Stress Management (Most Important)

Cortisol dysregulation is almost always driven by chronic stress (physical, emotional, psychological). Addressing stress is non-negotiable.

Practices:

• Nervous system regulation: Breathwork, meditation, vagal toning, somatic practices, therapy (especially trauma-informed therapy, EMDR, somatic experiencing)
• Boundaries: Reduce demands, say no, protect time and energy
• Rest: Schedule downtime, allow yourself to do nothing
• Nature, movement, connection: All reduce cortisol and support HPA axis health
• Address trauma and chronic stressors: Unresolved trauma and ongoing life stress (relationships, work, caregiving) are major drivers of cortisol dysregulation

2. Sleep Hygiene

Sleep is essential for cortisol regulation (cortisol rhythm is tied to circadian rhythm):

• Consistent sleep/wake times → even on weekends
• Morning light exposure → helps set circadian rhythm, supports healthy cortisol awakening response
• Limit evening light (especially blue light from screens) → allows cortisol to decline, melatonin to rise
• Cool, dark, quiet room → supports deep sleep
• Avoid caffeine after noon → caffeine raises cortisol and disrupts sleep
• Limit alcohol → alcohol disrupts sleep architecture, raises cortisol

3. Nutrition

Blood sugar stability is critical for cortisol regulation:

• Eat protein and healthy fats at every meal → stabilizes blood sugar, reduces cortisol spikes
• Avoid skipping meals → low blood sugar triggers cortisol release
• Limit refined carbs and sugar → blood sugar spikes and crashes raise cortisol
• Eat breakfast → supports healthy cortisol rhythm (some women do well with intermittent fasting, others don't—listen to your body)
• Support adrenal health: Adequate sodium (if low blood pressure), vitamin C, B vitamins, magnesium

4. Exercise (Moderate, Not Excessive)

Exercise affects cortisol in a U-shaped curve:

• Moderate exercise → reduces cortisol, improves stress resilience, supports HPA axis health
• Excessive or intense exercise → raises cortisol, worsens HPA axis dysfunction (if already dysregulated)

Recommendations:

• If cortisol is high: Focus on walking, yoga, tai chi, gentle movement (avoid intense cardio or heavy lifting until cortisol stabilizes)
• If cortisol is low: Gentle movement only (restorative yoga, walking); avoid intense exercise until adrenals recover
• If cortisol is healthy: Full range of exercise is beneficial (strength training, cardio, HIIT)

5. Adaptogenic Herbs and Supplements

Adaptogens help modulate cortisol and support HPA axis resilience:

For high cortisol:

• Ashwagandha (300-600 mg daily) → reduces cortisol, improves stress resilience, supports sleep
• Rhodiola (200-400 mg daily) → supports energy and resilience without raising cortisol
• Holy basil (tulsi) → reduces cortisol, supports calm
• L-theanine (100-200 mg) → promotes calm without sedation, reduces cortisol response to stress
• Phosphatidylserine (300-400 mg before bed) → blunts nighttime cortisol, supports sleep

For low cortisol (adrenal support):

• Licorice root (use cautiously; can raise blood pressure) → slows cortisol breakdown, raises cortisol levels
• Rhodiola → supports energy and resilience
• Vitamin C (1000-2000 mg daily) → adrenals need vitamin C for cortisol production
• B-complex vitamins → support adrenal function and energy
• Magnesium glycinate (300-400 mg) → supports HPA axis, improves sleep

General adrenal support:

• Adaptogenic blends (ashwagandha, rhodiola, holy basil, schisandra, eleuthero)
• DHEA (if low on testing; supports adrenal function and sex hormone production)

Note: Work with a knowledgeable practitioner; adaptogens are powerful and can backfire if used incorrectly.

6. Hormone Replacement Therapy (HRT)

Estrogen and progesterone therapy can help regulate cortisol:

• Progesterone → calming, GABA-enhancing effects buffer stress response, reduce cortisol reactivity, improve sleep
• Estrogen → supports HPA axis regulation, improves stress resilience
• Result: Many women on HRT report improved sleep, reduced anxiety, better stress tolerance (all signs of improved cortisol regulation)

7. Medication (If Severe)

In rare cases of true adrenal insufficiency (Addison's disease):

• Hydrocortisone (low-dose cortisol replacement) is medically necessary

For HPA axis dysfunction (not Addison's):

• Medication is rarely needed; lifestyle, stress management, and supplements are first-line

When to Review with Clinician

You should discuss cortisol if:

• Severe fatigue, especially if worse in the morning or after exertion
• Chronic insomnia (especially wired-but-tired pattern)
• Severe anxiety or feeling "on edge" all the time
• Weight gain (especially abdominal) despite healthy habits
• Dizziness, low blood pressure, salt cravings (possible adrenal insufficiency)
• Low stress resilience (everything feels overwhelming)
• Interested in testing cortisol rhythm (salivary 4-point test)
• Symptoms of Cushing's syndrome (very high cortisol: rapid weight gain, moon face, purple stretch marks, high blood pressure, high blood sugar)
• Symptoms of Addison's disease (very low cortisol: severe fatigue, weight loss, low blood pressure, salt cravings, darkening skin)

Red flags requiring medical attention:

• Severe fatigue with weight loss, low blood pressure, nausea, vomiting (possible Addison's disease—life-threatening if untreated)
• Rapid weight gain, very high blood pressure, new diabetes (possible Cushing's syndrome)
• Suicidal thoughts or severe depression (hormone-related or not, needs urgent care)

Related Terms

• estrogen
• progesterone
• thyroid-hormones
• insulin
• insomnia
• anxiety
• wired-but-tired
• the-patience-gap
• adrenal-fatigue
• hpa-axis-dysfunction
• wild-tide
• weight-gain