We have learned broadly applicable lessons on stress, energy balance, and resilient systems while working to mitigate the effects of prolonged high-dose steroids for one of our patients. Sharing them here:

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1-2% of the adult population is prescribed long-term steroids. Unlike many other drugs that are foreign “artificial” additions to our bodies, cortisol is particularly interesting to study because we all produce and modulate it every day. 

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What does this stress hormone do? A lot, both when it’s in balance and when it’s deranged:

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With its initial spike, cortisol makes you feel excited, energized, and sleep less. It increases your metabolism. Your body naturally produces more cortisol to wake you up in the morning and in response to stresses like illness, injury, and exercise. 

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In healthy states, cortisol upticks are transient, with accompanying periods of cortisol suppression. On any given day, your cortisol decreases 10-fold just from waking up to going to sleep (circadian rhythm), superimposed on peaks and valleys based on your activities (ultradian rhythm).

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But if cortisol is chronically elevated, the stress-response activities start to overwhelm restorative, recovery-oriented activities that also need time in dominance: 

• Leaching of minerals from bone breakdown exceeds new collagen deposition and bone formation 
• Muscle atrophies, particularly the fast twitch fibers which enable explosive movement
• Skin thins and loses its supportive matrix for strength and elasticity
• Insulin resistance develops through release of fatty acids and decreased lipolysis
• Immune system function and sex hormone production is suppressed
• Less fat is oxidized for energy and more fat collects around the viscera and center of the body

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How does cortisol become chronically elevated? Like our client, it could be from taking steroids for a long time, hijacking your body’s own regulation of these levels. But there are also ways levels can be thrown out of balance by the body’s own intrinsic production. 

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Chronic elevation of cortisol is seen in both starvation states, for example in patients with anorexia nervosa, AND in obesity/overfed states. Most fascinating to me, high cortisol from starving, overeating, and drugs share an unintuitive problem: high resting cortisol blunts the ability to get cortisol higher.

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Almost every cell in the body has cortisol receptors, and though cells don’t always need high levels of cortisol, when they do need it, they really need it. The most dangerous consequence of prolonged steroid use is called adrenal crisis and it can kill you. The body’s own production of steroids fails to support the bare minimum needed for life, often occurring when a challenge to the body transiently raises the bar on what the bare minimum is.** 

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This gives us some insight into the “cure” for elevated cortisol: it’s not to take the cortisol away. 

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Cortisol isn’t good or bad. Just like sugar, or fat, or exercise, problems happen when it’s taken out of balance. And just like sugar, fat, and exercise, the ideal levels of cortisol vary between people (with some preserved patterns). 

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Boundaries set in the name of health consciousness with sugar, fat, and exercise also give us some insight into counterproductive patterns you could be led into with respect to your cortisol levels. Measuring cortisol more granularly to “optimize” cortisol presumes we know what optimal levels ought to be. We don’t. 

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Stress (and thus, cortisol) happens. A healthy body isn’t one that has eliminated all sources of stress –though people try to sell “health” programs to do this–  nor one that is constantly under a state of heightened stress –though people try to sell this pathway too. What matters more than the level at any point in time is the body’s capacity to respond to, withstand, and release stress.  

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Manipulating cortisol is a powerful tool and it’s not necessarily wrong to tweak. I will be the first to say that old guard physicians have done harm with steroids, not just the alternative medicine folks. You want your body’s own homeostatic mechanisms around stress to be in charge as soon as possible. Anyone telling you otherwise should be met with deep skepticism. 

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In the meantime, if your cortisol levels are causing negative effects, there are many things that can be done for each affected organ system. Find dispassionate experts who have no specific agenda to sell and ask them to review your medical situation and any advice you’ve been given. 

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You should do this diligence for any medical decision where you think some nuance to your case is perhaps being missed. Checking what doctors, influencers, and supplement companies tell you before acting is well worth the effort.

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*The steroids referred to here are corticosteroids, distinct from anabolic steroids like testosterone, which deserve their own article on how they work in the body.

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**Adrenal crisis occurs in a specific subset of people. This life-threatening diagnosis is different from adrenal fatigue, which is not life-threatening and means different things to different practitioners, and also has been labeled on patients who we have evaluated and found to have no adrenal issues. 

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