health

The Truth Behind All That Cortisol Talk

Photo-Illustration: by The Cut; Photo: Orbon Alijay/Getty Images

Are you suffering from the effects of high cortisol, or are you just scrolling through your “For You” page on TikTok? “I swear, some days every half-hour I see a different person who is convinced that they have high cortisol,” says Dr. Divya Yogi-Morren, the medical director of the Cleveland Clinic Pituitary Center. The familiar-sounding hormone, it turns out, is a magical mystery key to nearly every ailment of modern life — poor sleep, weight gain, adult acne — at least according to the many, many influencers, professional medical background or not, on both the clock app and Instagram.

High cortisol is correlated with a broad set of symptoms, including weight gain (especially in the midsection and face), sleep problems, acne, intense cravings for sweet or salty foods, and difficulty maintaining energy levels throughout the day. One common way of describing the experience of high cortisol is feeling “wired and tired.” High cortisol is a real medical condition, and many of these symptoms can be telltale signs — not of a definitive diagnosis but of a need for further testing.

It’s also, unsurprisingly, social-media catnip. Looking for a way to lose weight? To feel more energetic? To make it through the midafternoon slump? Those could all lead you to high-cortisol content. What social media says to do about all that cortisol ranges from true to “unproven but harmless” to absolute snake oil. It’s true that elevated cortisol levels can cause a host of symptoms, including specific weight-gain patterns and sleep issues, but can a quick walk in morning light as soon as you get up help regulate your circadian rhythms? As long as you look both ways before you cross the street, what’s the harm? Those pricey adaptogen powders with murky ingredient lists that promise to lower cortisol levels, however — not actually a thing, Dr. Yogi-Morren says, citing the lack of reliable studies that show any connection between the two. And there’s no reason to buy cortisol tests from someone online. If you’re concerned enough to do this, consult your primary-care doctor to get properly tested.

In other words: Obviously, cortisol is far more complex than TikTok would lead you to believe. Which is why we’ve put together the following guide to what cortisol actually is, how it works in the body, and when to close TikTok and call your doctor. After watching far too many high-cortisol videos on TikTok, I compared the common themes that pop up on social media to what researchers have investigated by reading through more than a dozen medical research studies from trusted sources like the Journal of the American Medical Association (JAMA), Psychosomatic Medicine Journal of Biobehavioral Medicine, and American Journal of Human Biology, and consulting the National Institutes of Health, the Cleveland Clinic, and the Mayo Clinic. Then, I talked to Dr. Yogi-Morren, an endocrinologist who specializes in the pituitary gland, where it all starts.

So, what even is cortisol?

A steroid hormone that serves a number of purposes in the body. (Hormones are chemicals that travel through the bloodstream with instructions for other glands.) Cortisol production starts in the blueberry-size pituitary gland. “It’s the hormone control tower of the body,” says Dr. Yogi-Morren. “It’s the most important gland in regulating the production of cortisol in your adrenal glands.” While not located in the brain itself, it hangs down from the base of the brain and is connected to the hypothalamus, “so it gets a lot of signaling from the brain,” Dr. Yogi-Morren says.

When, at the brain’s request, the pituitary gland releases adrenocorticotropic hormone (ACTH), that’s a message for the adrenal glands, which sit atop the kidneys, to produce cortisol. Cortisol can suppress inflammation and control metabolism in the muscles, fat, liver and bones, and it has an effect on our circadian rhythms, or sleep-wake cycles.

High cortisol is a real condition, says Dr. Yogi-Morren. However, not all high cortisol is the same, and understanding the different reasons behind elevated cortisol levels is crucial. “You can have high cortisol from different stressors in your life, and there are things you can do to reduce your stress, and hence reduce your cortisol,” she says. This is different, she stresses, from underlying disease, which can also cause high cortisol. Usually, the medical condition that leads to high levels of cortisol is a tumor, in either the pituitary or adrenal gland.

Elevated cortisol has a wide variety of symptoms, including weight gain, sleep problems, elevated blood pressure, a rounded hump between the shoulders, dark-reddish or purple stretch marks, and muscle weakness. It’s hard to say how common it is to experience elevated cortisol levels that are a result of stress. This is a physiological reaction that we’re guaranteed to experience when we get a weird email from a manager, have to endure a holiday gathering with a difficult relative, or sit on a stalled subway train on the way to an important work meeting. The important characteristic of stress-related cortisol peaks is that they’re transient — they’ll pass. Tumors, on the other hand, are rare. Cushing’s syndrome, which is usually a tumor of the adrenal or pituitary gland that can cause a number of different serious health problems, occurs in one in 40 to 70 million people, according to the National Institutes of Health (NIH). Cushing’s syndrome, without the tumor, can also be a side effect of certain medications, but prescribing doctors will be on the lookout.

If you’re just more stressed out than normal, these temporary fluctuations in cortisol level may respond to lifestyle changes like making more time for sleep, getting regular exercise, and doing things you enjoy, like knitting, bike riding, or hanging out with friends. If you have a tumor, those changes might make you feel a little better, but they won’t really make a dent in your symptoms, and they certainly won’t do anything to address the underlying cause.

Stress can be addressed by lifestyle changes; a tumor requires surgery. A diagnosis from a medical professional is required to differentiate between the two causes of high cortisol. “Management of stress and management of your life is a separate issue from a disease that causes high cortisol,” Dr. Yogi-Morren says.

How is stress related to cortisol?

Chances are you’ve probably heard someone call cortisol the “stress hormone” — the chemical reaction that fuels our fear response to, say, being chased by a lion. But in modern life, acute stress like the lion chase (think being stuck in traffic or taking a friend to the emergency room or being laid off from work) exists alongside, and is often overshadowed by, chronic stress (the economy, politics, balancing work and life).

Stress can raise our cortisol levels, and our brain-pituitary-adrenal connection is designed to do exactly that, but in a protective way. (There is a wide range of “normal” cortisol levels for adults, so there is no one test that can determine whether you’re above your baseline, unless you’ve been monitoring them for some time.) So when we see the proverbial lion, we’re able to react to the immediate threat with maximal energy and mental acuity. But that reaction is supposed to be temporary. Once the threat is gone — the lion has stalked off in a different direction and we’ve returned to safety, or we’re out of the traffic jam or off the stalled subway car and have made it to our meeting on time — our cortisol production returns to normal. Chronic stress can keep that pathway activated and our cortisol levels high. While stress-related cortisol issues may be managed through exercise, sleep, mindfulness practices, and other strategies, their root cause is external — some kind of significant loss, financial strain, or, say, a global pandemic. Even if you are suffering from chronic stress, it’s finding a way to deal with the root cause, not a supplement, that’s going to be helpful.

Can high cortisol really cause weight gain?

Not exactly shocking for a culture fixated on body size, much online chatter about cortisol levels can feel like diet talk dressed up as wellness. It won’t take long scrolling through the cortisol corner of TikTok to see a video about how to slim your face and abdomen. Typically, the star is some sort of “health and wellness” creator promoting what is essentially a weight-loss program with specific diet and exercise recommendations but which attributes that weight to elevated cortisol levels. Adaptogens, often sold by said creator, or some other supplement in pill or powder form are usually part of the equation.

Body size fluctuates for lots of different reasons, many of which are completely normal. Whether there’s a connection between weight and cortisol depends on where the weight gain is happening. High levels of cortisol can lead to weight gain in the abdomen (“belly fat” in Instagram-ad-speak) and face, a symptom that is sometimes referred to as “moon face” for the round shape that even a long, thin face can take on. So, yes, a newly round face or weight gain in your midsection could possibly be a symptom of high cortisol levels. Fat deposits on the upper back, above the shoulder blades, or around the collarbones may also point to a problem with cortisol. Weight gain in your arms and legs or a bigger, rounder butt are not connected. Simply gaining a few pounds, even if they are in your abdomen or face, is probably not cause to see a doctor, unless you are also experiencing another symptom of high cortisol, like newly elevated blood pressure, dark stretch marks, or sleep issues.

By the way, some studies have shown that dieting itself can lead to higher production of cortisol. A 2010 study published in the Psychosomatic Medicine Journal of Biobehavioral Medicine created four groups: one that restricted calories and tracked what they ate each day, one that ate a calorie-restricted diet without tracking, one that tracked what they ate without counting calories, and a control group that ate normally with no tracking. Both groups restricting calories saw an increase in cortisol, and those that tracked calories experienced an increase in perceived stress.

What about the effects of high cortisol on sleep?

Our cortisol levels naturally rise and fall throughout the day with our circadian rhythms, the complicated system of hormones and other physical and mental cues that keep our bodies in tune with a 24-hour light-and-dark cycle. Part of the process of waking up in the morning is associated with a rise in cortisol, which then falls in the evening as our bodies prepare for sleep. This is a bit of a chicken-and-egg problem. Poor sleep habits, like doom scrolling before bed, can increase cortisol. But high cortisol can also disrupt sleep.

Other potential effects include high blood sugar, high blood pressure, hair loss or new growth patterns, acne, muscle weakness, and bone weakening and fractures.

When should you see a doctor?

If you have a cluster of symptoms that is interfering with your daily life, whether that’s because you’re barely functioning due to lack of sleep, or your body is changing in ways you don’t understand, or you find yourself experiencing high blood pressure or muscle weakness, see your doctor. If she suspects that you are suffering from high cortisol, she will perform a series of tests: a 24-hour urine test (yes, all your pee in a 24-hour period, stored in the refrigerator — warn your roommate), blood tests that look at specific cortisol secretions, and, to round out the effluvia collection, a midnight saliva test, in which you spit into a special test tube at midnight, when your cortisol levels should be quite low. How much you’ll pay for these will vary depending on your insurance, though they are all basic laboratory tests and not more expensive imaging. Some influencers sell saliva test strips, but Dr. Yogi-Morren says that to accurately diagnose high cortisol, you need to do all three tests in tandem and under medical supervision.

If just one of these tests comes back positive, you may have higher cortisol levels than normal, and the condition may be stress-related. Two or more positive markers can indicate that there may be a tumor in either the pituitary or adrenal gland. These tumors are usually benign, but they need to be diagnosed using medical imaging like a CT scan or MRI and then surgically removed.

Even stress-related high cortisol can have negative health effects, like high blood pressure, elevated blood-sugar levels, and chronic sleep deprivation, all which can have a very real impact on your overall health and well-being, even if there is no tumor to remove. If you have stress-related cortisol issues, think about how to implement Dr. Yogi-Morren’s suggestions for lowering your cortisol levels. Get good quality sleep, ideally six to eight hours a night. Regular aerobic exercise can both improve sleep quality and lower stress. Deal with stress through therapy, meditation, and other strategies that work for you — maybe that’s making time to go to yoga, a weekly date with a friend, spending time outdoors, or getting into a hobby like knitting or doing crossword puzzles. If you feel yourself getting stressed in a lion-type situation, deep breathing can be useful. And, as difficult as this can be, cultivating relationships at home and at work and identifying ways to deal with specific stressors can help. “Generally, trying to cultivate a happy and healthy life,” says Dr. Yogi-Morren. “When you laugh, you release endorphins, and this suppresses cortisol secretion for real; being happy can actually make you healthy.”

What about lifestyle changes and mindfulness?

If you’re getting health advice from TikTok, then you may know that self-proclaimed cortisol experts counsel against high-impact exercise like high-intensity interval training (HIIT) workouts and weight lifting. Dr. Yogi-Morren says that, in theory, this is correct; intense exercise damages our muscles, and the process of regrowth makes them stronger. All of this raises cortisol. But, she says, this should not be a problem if there is not an underlying medical condition, like Cushing’s syndrome. Influencers also often recommend tapping on the body to regulate stress, similar to a deep-breathing practice in some ways. Dr. Yogi-Morren says tapping has not been shown to be helpful by any studies, so she prefers breathwork or meditation as stress-reduction strategies — but tapping is also free and harmless, so if it’s an established practice that makes you feel good, keep doing it. And, again, don’t purchase supplements, adaptogens, or tests from the internet. See your doctor if you suspect your cortisol levels are elevated.

“I practice virtual medicine,” says Dr. Yogi-Morren. “I have virtual visits, but I’m pretty sure that there’s no law where you can practice medicine through TikTok.”

The Truth Behind All That Cortisol Talk