Raised and Lowered Cortisol: Treatment – Normal Cortisol Levels

Cortisol is one of the hormones that play an essential role in maintaining the body's internal balance. When its levels fall outside the normal range, changes occur that can affect numerous vital processes.

Do you constantly suffer from anxiety, from exhaustion that doesn't lift even after sleeping, or even from changes to your menstrual cycle? A cortisol imbalance could lie behind these signals. Find out which levels are considered normal, how raised or lowered cortisol affects you in the long term, and what treatment options are available.

What is cortisol

Cortisol is a glucocorticoid, a steroid hormone produced by the adrenal cortex in the zona fasciculata and released into the bloodstream. Cortisol secretion is governed by the hypothalamic-pituitary-adrenal axis (HPA axis), with adrenocorticotropic hormone (ACTH) directly stimulating its production.

Although it is referred to as the "stress hormone", cortisol regulates processes that affect almost every organ and tissue in your body. It influences carbohydrate metabolism, the immune system, blood pressure, the sleep-wake cycle and – as its nickname suggests – the body's response to stressful situations.

How cortisol is produced and regulated – the regulatory mechanism of cortisol

Cortisol production is regulated via the hypothalamic-pituitary-adrenal axis, a complex hormonal system that responds rapidly to the body's needs.

The process begins in the hypothalamus, which releases corticotropin-releasing hormone (CRH). This stimulates the release of adrenocorticotropic hormone (ACTH) from the anterior pituitary, and ACTH acts on the adrenal glands to trigger cortisol secretion.

Once cortisol levels have risen sufficiently, cortisol acts on the hypothalamus and pituitary through a negative feedback mechanism to reduce the production of CRH and ACTH.

This is how the body's hormonal self-regulation normally works. However, when this system falls out of step, imbalances such as raised or markedly elevated cortisol can develop.

The circadian rhythm of cortisol and daily fluctuations

Cortisol levels fluctuate throughout the day and are usually higher in the morning and lower in the evening. This cycle is known as the circadian rhythm; it is clearly defined and aligned with the sleep-wake cycle.

Levels peak in the morning, typically between 6 and 8 a.m., to prepare the body for activity and energy expenditure, and then gradually decline towards the evening so that relaxation can set in and sleep comes more easily.

This natural rhythm can be disrupted by sleep disorders, an irregular daily routine or persistent stress.

Cortisol in the morning vs. cortisol in the evening – interpreting cortisol levels

Cortisol levels are physiologically higher in the morning, when the body is preparing for the day's energy expenditure. In the evening, levels should be considerably lower.

If this difference is absent, it suggests abnormal cortisol levels. If levels remain elevated in the evening too, this may indicate excessive cortisol secretion (hypercortisolism), while low morning levels may point to possible adrenal insufficiency.

For this reason, cortisol is always assessed within the clinical context and sometimes requires additional tests for a correct diagnosis.

Cortisol and sleep – the link between cortisol and sleep

Cortisol directly influences the sleep-wake cycle and the body's level of alertness.

Normally, the decline in production during the second half of the day helps to induce drowsiness. If cortisol levels remain elevated in the evening, they can cause insomnia and set a genuine vicious circle in motion. Lack of sleep or poor sleep quality can lead to a rise in cortisol the following day, perpetuating this cycle.

In the long term, a cortisol imbalance affects sleep quality as well as metabolism, immune function and emotional balance.

The role of cortisol in the body – the key functions of cortisol

Although cortisol is mostly associated with stress, it is involved in processes that support the internal balance of the entire body:

• It stimulates gluconeogenesis and a rise in blood sugar, thereby governing how the body uses glucose to generate energy.
• It is involved in protein and fat metabolism.
• It has anti-inflammatory and immunosuppressive effects, which is why synthetic cortisol derivatives are often used to control inflammation.
• It helps regulate blood pressure.
• It plays a central role in the "fight or flight" response, preparing the body to react quickly in the face of danger.
• It influences memory and cognitive function by acting on specific brain regions involved in processing information and regulating emotions.

Cortisol and stress – how stress affects cortisol levels

Stress is the most important factor behind cortisol fluctuations. In acute stress, cortisol rises temporarily so that the body can adapt quickly, and then returns to normal.

Problems arise when stress becomes chronic and cortisol remains permanently elevated. This can lead to dysregulation of the HPA axis, and a long-term excess of cortisol can impair metabolic and mental health.

Cortisol and weight gain around the abdomen

Studies have shown that fat cells in the visceral region have more cortisol receptors than those elsewhere in the body, making them more sensitive to the hormone's effects. Raised cortisol can therefore promote fat storage around the abdomen.

Of course, elevated cortisol levels alone do not automatically lead to the accumulation of visceral fat. A balanced diet and an active lifestyle remain the foundation of a healthy body weight.

However, another effect of raised cortisol is an increased appetite, particularly for foods high in sugar or fat and therefore also high in calories. The more frequently such foods are eaten, the greater the likelihood of a calorie surplus and the risk of weight gain and visceral fat storage.

Unlike subcutaneous fat, which is visible on the thighs or hips, for example, visceral fat carries a range of serious health risks. It is metabolically active and continuously releases cytokines (pro-inflammatory substances) into the portal vein, which carries blood to the liver – this can increase the risk of cardiovascular disease, insulin resistance, diabetes and metabolic syndrome.

Cortisol and sleep disorders

High cortisol keeps the body in a state of alert. If this state persists into the second half of the day or even into the evening, difficulty falling asleep and frequent night-time waking can occur, shortening the deep sleep phases and increasing the risk of insomnia. Conversely, lack of sleep can increase cortisol secretion the following day, perpetuating a vicious circle that is hard to break.

Cortisol and anxiety or depression

Hypercortisolism (an excess of cortisol) is frequently linked with anxiety, since raised levels of this hormone keep the body on alert and can heighten tension, irritability and hypervigilance. As cortisol also influences neurotransmitters such as serotonin and dopamine, which are involved in regulating mood, cortisol imbalances can contribute to the development of symptoms of depression.

Cortisol and menstruation – the influence of cortisol on the menstrual cycle

Because of its links to the HPA axis, cortisol is also involved in maintaining the hormonal balance that underpins menstrual health. Long-term elevated levels can disrupt the hormones involved in ovulation and menstruation and cause irregular menstrual cycles.

Put differently, an excess of cortisol can inhibit the secretion of GnRH (gonadotropin-releasing hormone) in the hypothalamus, which leads to reduced release of LH (luteinising hormone) and FSH (follicle-stimulating hormone) from the pituitary. These hormones play an essential role in the maturation of the ovarian follicles and in triggering ovulation; their dysregulation can disrupt the menstrual cycle and lead to irregular or even absent periods.

Since high cortisol can also trigger muscular tension and increase inflammation in the body, it can heighten the perception of pain and worsen period pain. Make sure you use menstrual products made with natural, skin-friendly ingredients and without harsh chemicals, which can increase the risk of irritation or inflammation at this time.

In the long term, chronic stress combined with high cortisol levels can impair fertility through its negative effects on ovulation and hormonal balance.

Normal cortisol levels – interpreting cortisol test results 

Cortisol levels are normally higher in the morning and fall gradually throughout the day until they reach their lowest point in the evening. Interpreting cortisol results must take these physiological fluctuations, the time of blood sampling and the patient's clinical context into account. 

Reference ranges may vary slightly depending on the laboratory and the method used. Results are usually reported in µg/dl or nmol/l, and conversion between the units must be precise for an accurate assessment.

Besides serum testing (measuring the cortisol level in the blood), there are other useful methods of investigation:

• Measuring cortisol in saliva can be helpful for assessing the circadian rhythm, as it allows repeated measurements at different times of day.
• Measuring cortisol in a 24-hour urine collection is particularly indicated where Cushing's syndrome is suspected, as it allows the most precise assessment of total daily secretion.

Factors such as acute stress, pregnancy, taking oral contraceptives or physical exertion before the blood sample can affect the results. For this reason, the doctor will always assess the levels in the light of each patient's symptoms and medical history.

Raised cortisol (hypercortisolism) – causes and symptoms of a high cortisol level

Hypercortisolism refers to a condition characterised by excessive cortisol production over a prolonged period.

It can have endogenous causes – that is, excessive cortisol secretion within the body as a result of pituitary or adrenal tumours – as well as exogenous causes such as taking corticosteroids to treat inflammatory or autoimmune conditions.

Chronic stress is another factor that can contribute to a rise in cortisol and lead to hypercortisolism.

The accumulation of visceral fat, purple stretch marks – particularly on the abdomen – arterial hypertension, raised blood sugar, muscle weakness and cycle disturbances are among the signs of a high cortisol level.

Raised cortisol and Cushing's syndrome

Cushing's syndrome is the severe form of hypercortisolism and is caused by sustained exposure to high cortisol levels. It can arise from pituitary tumours that produce excessive ACTH, or from adrenal tumours that release too much cortisol.

An endocrinological assessment is required to make the diagnosis. Measuring cortisol in a 24-hour urine collection, measuring blood cortisol at midnight and measuring late-evening salivary cortisol are the key tests for confirming Cushing's syndrome.

Raised cortisol due to taking corticosteroids

Prolonged treatment with corticosteroids such as prednisone or dexamethasone for inflammatory or autoimmune conditions can increase the overall cortisol level in the body and produce symptoms resembling Cushing's syndrome, such as hypertension or a rise in blood sugar.

As suddenly stopping such therapy can have serious consequences, the dose must be adjusted under the medical supervision of a specialist.

Raised cortisol and pituitary or adrenal tumours

Certain tumours can release excessive ACTH in the pituitary or excessive cortisol in the adrenal gland, thereby causing major hormonal imbalances and the typical symptoms of hypercortisolism.

Blood, urine and saliva tests are required to measure the cortisol level and establish the cause; treatment usually consists of surgical removal of the tumour.

Raised cortisol and chronic stress

Persistent stress keeps the HPA axis active and leads to permanently elevated cortisol secretion, which promotes functional hypercortisolism – even in the absence of a tumour or any other endocrine disorder.

This manifests as the accumulation of abdominal fat, a rounded face, the appearance of purple stretch marks, hypertension, muscle weakness, cycle disturbances and, in the long term, osteoporosis and fractures.

Low cortisol (adrenal insufficiency) – causes and symptoms of a low cortisol level

Specialists use the term adrenal insufficiency for abnormally low cortisol levels. It is a serious chronic condition in which the adrenal glands do not produce the required amount of hormones (cortisol and aldosterone).

There are two forms of adrenal insufficiency: primary and secondary. Primary insufficiency, also known as Addison's disease, occurs when the immune system attacks the adrenal glands. Secondary insufficiency is caused by an ACTH deficiency, brought about by hypopituitarism or a pituitary tumour.

Other possible causes of a low cortisol level include the abrupt discontinuation of corticosteroid therapy, infection or bleeding within the adrenal tissue.

Low cortisol and Addison's disease

Addison's disease refers to a serious chronic condition affecting the adrenal glands. It is a common autoimmune disorder in which the immune system attacks and destroys the adrenal glands, reducing the production of cortisol and aldosterone.

Low cortisol and secondary adrenal insufficiency

Secondary adrenal insufficiency occurs when the pituitary does not release enough ACTH, usually because of pituitary disorders or the abrupt discontinuation of corticosteroid therapy.

Without the stimulus of ACTH, the adrenal glands do not produce enough cortisol; a low cortisol level manifests as severe exhaustion, hypotension, hypoglycaemia, hyperpigmentation, weight loss and salt cravings.

A serious complication of secondary adrenal insufficiency is an Addisonian crisis, a medical emergency characterised by a sudden drop in cortisol and presenting with severe hypotension, vomiting, intense abdominal pain, dehydration and loss of consciousness – immediate treatment is required here.

How cortisol is tested – methods of cortisol analysis

The amount of cortisol in the body can be measured using various methods; most commonly, however, a blood test is carried out to determine serum cortisol. The sample is usually taken in the morning, when levels are physiologically higher, but in some cases the doctor will also recommend an evening sample to assess the circadian variation.

Other methods of assessing cortisol include:

• Saliva test: assesses free cortisol and allows repeated measurements at different times of day.
• 24-hour urine test: measures total daily secretion and is frequently used where Cushing's syndrome is suspected.
• Dexamethasone suppression test: examines how the body regulates its hormone secretion where hypercortisolism is suspected.
• ACTH stimulation test: assesses the adrenal glands' ability to produce cortisol where adrenal insufficiency is suspected.

To make the diagnosis, the endocrinologist takes into account both the test results and each patient's medical context and symptoms.

How to lower your cortisol level naturally – methods of reducing cortisol

In Cushing's syndrome, medication or surgery is required to lower cortisol. However, if raised cortisol is the result of chronic stress, you can support its reduction naturally through changes to your lifestyle:

• Keep a regular sleep schedule with 7–9 hours of sleep a night to regulate your circadian rhythm and reduce the risk of excessive cortisol secretion during the day.
• Try to get exposure to natural light in the morning to help regulate your internal clock.
• Take regular, moderately intense exercise, which can improve the body's stress response.
• Practise relaxation techniques such as diaphragmatic breathing, meditation or yoga.
• Cut down on caffeine, particularly in the second half of the day.
• Eat a balanced diet with enough protein and essential nutrients to support stable blood sugar levels.
• If you are under chronic stress, seek psychotherapeutic support to manage the emotions that sustain excessive cortisol secretion.

Treating cortisol imbalances – therapeutic options

The endocrinologist determines the treatment of a cortisol imbalance according to its cause and severity.

A low cortisol level can be treated with hormone replacement therapy using hydrocortisone, which makes up the deficiency and prevents complications.

Where hypercortisolism is caused by a tumour, surgery is usually the first treatment option. If an operation is not possible, or until it can be carried out, the doctor may recommend radiotherapy to the pituitary or treatment with medicines that inhibit cortisol production in the adrenal gland.

Whatever the cause and therapeutic approach, after diagnosis the patient is monitored by an endocrinologist over the long term in order to adjust treatment and prevent relapse or complications.

Frequently asked questions about cortisol

Because of its association with high stress, cortisol often has a bad reputation. Yet this hormone is involved in numerous vital bodily processes, and not every imbalance can be corrected by better stress management. Sometimes levels that are too high or too low have hormonal causes and require thorough medical investigation.

If you still have questions about testing methods and how cortisol levels affect health, below you will find answers to the most common questions, which will hopefully clarify everything you need to know about cortisol.

What does raised cortisol mean?

Raised cortisol means a level above the range considered normal for this hormone. It may be linked to chronic stress or to conditions such as Cushing's syndrome, in which excessive cortisol secretion affects metabolism, sleep and hormonal balance.

Does stress raise cortisol permanently?

Acute stress causes a temporary rise in cortisol, which helps the body adapt to demanding situations. Chronic stress, however, can keep cortisol high over the long term and have negative effects on general health.

What are normal cortisol levels in the morning?

In the morning, cortisol levels are naturally higher than in the evening, as the body prepares for the day's activities. The exact reference ranges may vary from laboratory to laboratory.

Does cortisol affect weight?

A raised cortisol level can increase appetite and trigger cravings for calorie-dense foods high in sugar and fat; eating these makes it easy to slip into a calorie surplus that leads to weight gain. Raised cortisol also promotes the storage of abdominal fat and can affect metabolism, contributing to weight gain and difficulties in regulating blood sugar.

How do I lower cortisol quickly?

If cortisol is raised in response to acute stress rather than for other medical reasons, it can be lowered naturally through deep breathing techniques, relaxation or meditation. Regular breaks, moderate exercise and good sleep also help to reduce acute stress and cortisol.

What is the link between cortisol and anxiety?

Elevated cortisol levels can heighten states of alertness and tension; the hormone is directly involved in the biological mechanisms that generate anxiety.

When is the dexamethasone suppression test for cortisol recommended?

The test is carried out to confirm suspected hypercortisolism and for the differential diagnosis of the causes of a rise in cortisol. It allows the doctor to determine whether the excess originates in the pituitary, the adrenal glands or from taking corticosteroids.

What are the symptoms of low cortisol?

A low cortisol level can manifest as severe exhaustion, low blood pressure and weight loss. Hyperpigmentation, salt cravings and episodes of hypoglycaemia are also among the symptoms of a low cortisol level.

Does cortisol affect sleep?

Yes, cortisol plays a central role in regulating the sleep-wake cycle, and elevated levels in the evening can cause insomnia. The circadian rhythm is crucial for restorative sleep, which is why cortisol levels should fluctuate evenly throughout the day – peaking in the morning and declining gradually towards the evening.

What is the difference between Cushing's syndrome and hypercortisolism?

Hypercortisolism refers to an excess of cortisol in the body, whereas Cushing's syndrome is the clinical expression of that excess – with visible symptoms such as hypertension and metabolic disturbances.

Can low cortisol cause low blood pressure?

Yes, low cortisol levels reduce the body's ability to maintain blood pressure, which can lead to hypotension, particularly in stressful situations.

Which test for cortisol is more accurate: saliva or serum?

Which test is appropriate for measuring cortisol depends on the clinical context. Serum cortisol provides a snapshot of the hormone, salivary cortisol allows measurements at different times of day, and 24-hour urinary cortisol is recommended where Cushing's syndrome is suspected. The doctor will often recommend a combination of several testing methods to obtain a complete picture.

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