Cortisol Abnormal

When cortisol levels in your body become too high or too low, it can lead to serious health problems that affect nearly every part of your body, from your blood pressure and weight to your energy levels and immune system.

Table of contents

• What is cortisol?
• Associated anatomy
• How cortisol affects your body
• High cortisol levels
• Low cortisol levels
• Testing for cortisol levels
• Treatment approaches

What is cortisol?

Cortisol is a hormone (a chemical messenger in your bloodstream) that your body makes in small glands called adrenal glands. These glands sit on top of your kidneys. Cortisol is a type of steroid hormone known as a glucocorticoid^[1].

• Adrenal glands
• Kidneys
• Pituitary gland
• Hypothalamus

Most people think of cortisol mainly as the “stress hormone” because your body releases more of it when you feel stressed. However, cortisol does much more than just help you handle stress. It affects almost every organ and tissue in your body^[1].

Your body carefully monitors and adjusts cortisol levels throughout the day to keep them steady. For most people, cortisol levels are highest in the morning right before waking up and lowest in the evening when going to sleep. This natural rhythm helps control your sleep-wake cycle^[1].

Associated anatomy

Several organs work together to control cortisol production in your body. Your hypothalamus (a small region at the base of your brain) and pituitary gland (a pea-sized gland in your brain) work together to tell your adrenal glands how much cortisol to make^[1].

The process works like this: When cortisol levels in your blood fall, your hypothalamus releases a substance called corticotropin-releasing hormone (CRH). This directs your pituitary gland to make adrenocorticotropic hormone (ACTH). ACTH then triggers your adrenal glands to make and release cortisol. To have healthy cortisol levels, your hypothalamus, pituitary gland, and adrenal glands must all be working properly^[1].

How cortisol affects your body

Cortisol plays many important roles in keeping your body healthy. It helps regulate how your body uses glucose (sugar) for energy, controls inflammation (swelling), manages blood pressure, and helps control your sleep-wake cycle^[1].

When you experience stress, your body releases cortisol after releasing “fight or flight” hormones like adrenaline. This helps you stay alert during stressful situations. Cortisol also triggers your liver to release glucose (sugar), which provides quick energy when you need it^[1].

Cortisol is responsible for maintaining constant blood pressure and blood glucose levels, regulating immune function and anti-inflammatory mechanisms, and controlling your body’s fight-or-flight response^[2]. The hormone affects your metabolism (the chemical processes that allow your body to function) by helping regulate how your body uses glucose for energy^[1].

In short bursts, cortisol can boost your immunity by limiting inflammation. However, if you have consistently high levels of cortisol, your body can get used to it, which can lead to inflammation and a weakened immune system^[1].

High cortisol levels

When your body has too much cortisol for a long time, this condition is called hypercortisolism. If high cortisol levels persist, it usually indicates Cushing syndrome^[1].

Causes of high cortisol

High cortisol levels and Cushing syndrome can be caused by taking high doses of corticosteroid medications (like prednisone, prednisolone, or dexamethasone), or by tumors that produce certain hormones^[1].

There are four main triggers related to Cushing syndrome. Pituitary tumors (abnormal growths in the pituitary gland) cause 70 to 80 percent of Cushing syndrome cases. Adrenal tumors are responsible for about 10 percent of cases. Ectopic tumors (tumors outside the adrenal or pituitary glands, most often in the lung) account for about 10 percent of patients. The fourth cause is excessive use of corticosteroid medications^[10].

Symptoms of high cortisol

High cortisol levels can cause many different symptoms. Physical symptoms may include weight gain (especially in the trunk, face, and upper back), a rounded face (sometimes called “moon face”), a fatty lump between the shoulders (referred to as a “buffalo hump”), pink or purple stretch marks on the stomach, hips, thighs, breasts, and underarms, thin and fragile skin that bruises easily, slow wound healing, and acne^[3].

Women with high cortisol may experience thick, dark hair on the face and body (a condition called hirsutism) and periods that are irregular or stop completely. Men with Cushing syndrome may also experience specific symptoms related to hormone changes^[3].

Other symptoms can include high blood pressure, high blood sugar, weak bones, and muscle weakness, especially in the upper arms and thighs^[5].

Too much cortisol can also affect your mood. Emotional changes may include depression, anxiety, mood swings, difficulty concentrating, and lower sex drive^[9].

Low cortisol levels

When your body does not produce enough cortisol, this is called hypocortisolism or adrenal insufficiency. There are two main types: primary adrenal insufficiency (also known as Addison disease) and secondary adrenal insufficiency^[4].

Causes of low cortisol

Primary adrenal insufficiency (Addison disease) happens when your adrenal glands cannot make enough cortisol because certain infections or diseases have damaged them^[4]. Secondary adrenal insufficiency occurs when your pituitary gland cannot make enough ACTH to tell your adrenal glands to make cortisol. Over time, your adrenal glands may shrink and stop working^[4].

Low cortisol levels can also happen if you stop taking steroid medications suddenly^[4].

Symptoms of low cortisol

Common symptoms of low cortisol may include long-lasting fatigue, muscle weakness, loss of appetite, weight loss, and abdominal (belly) pain^[4].

Additional symptoms can include low blood pressure, nausea or vomiting, low blood sugar, lightheadedness, irritability, depression, and dark patches of skin. Women with low cortisol may also experience decreased armpit and pubic hair and decreased sexual desire^[5].

These symptoms can develop slowly over time, making them easy to overlook initially^[2].

Testing for cortisol levels

A doctor can check cortisol levels with different types of tests. A cortisol test measures the level of cortisol in your blood, urine (pee), or saliva (spit)^[4].

For a blood test, a healthcare professional takes a blood sample from a vein in your arm using a small needle. Blood samples are usually taken twice during the day—once in the morning and once later in the day—because cortisol levels change throughout the day^[4].

Your provider may also order a urine test or saliva test. For urine testing, you may need to collect all your urine over 24 hours. Saliva samples can be collected at home at different times of the day, which is a convenient way to gather information about when your cortisol levels rise and fall^[4].

Normal cortisol levels vary depending on the time of day and the type of test. For most blood tests, normal ranges are 10 to 20 micrograms per deciliter in the morning (6 to 8 a.m.) and 3 to 10 micrograms per deciliter in the afternoon (around 4 p.m.)^[5].

Testing is usually only necessary when a person has very specific symptoms. The symptoms tend to be fairly dramatic, and if you are experiencing them, you should have testing done^[2].

When Cushing syndrome is suspected and is caused by the body making too much cortisol, diagnosing it can be a long and complex process. You will likely need to see a doctor who specializes in hormonal diseases, called an endocrinologist. The endocrinologist will likely do a physical exam and look for signs of the condition, such as a round face, a hump on the back of the neck, and thin, bruised skin with stretch marks^[13].

Treatment approaches

Treatment for abnormal cortisol levels depends on whether levels are too high or too low, and what is causing the imbalance.

Treating high cortisol

Treatments for Cushing syndrome aim to lower the body’s cortisol levels and improve symptoms. The sooner treatment starts, the better the chances for recovery^[3].

If you are taking glucocorticoid medications that are causing high cortisol, your healthcare provider can look at all your medicines—pills, injections, creams, and inhalers—to see if you are taking medicines that can cause the syndrome. If you are, you may need to gradually reduce your doses under medical supervision^[13].

If a tumor is causing your symptoms, you may need radiation therapy or surgery to remove it^[13].

Treating low cortisol

Treatment for low cortisol (Addison disease and adrenal insufficiency) involves taking medicines to correct the levels of steroid hormones that your body is not making enough of. Some treatments include corticosteroid medicines taken by mouth, such as hydrocortisone, prednisone, or methylprednisolone to replace cortisol. You take these medicines on a schedule that helps mimic the changes in cortisol levels the body typically goes through over 24 hours^[17].

People with primary adrenal insufficiency (Addison disease) also require a medicine called fludrocortisone acetate to replace another hormone called aldosterone. You will likely need plenty of sodium (salt) in your diet when taking this medication^[17].

Importance of treatment

Without treatment, abnormal cortisol levels can be very serious and even fatal over time. High or low cortisol levels can lead to health problems including infections, blood clots, depression, heart attack, weight gain, memory problems, high blood pressure, high cholesterol, broken bones, and type 2 diabetes^[16].

Regular monitoring for signs of under-replacement or over-replacement is essential during follow-up care. Patient education is a key feature of managing this condition^[20].