Cortisol From Stress: Implications for High Blood Pressure and Adrenal Fatigue

By: Michael Lam, MD, MPH

Read Part 1

Cortisol From Stress

Cortisol from stress can seriously affect blood sugar levels in those with adrenal fatigue Cortisol from stress may be having a greater impact on your health than you realize. The most important anti-stress hormone in the body is cortisol. Cortisol affects the body by normalizing blood sugar – Cortisol increases blood sugar level in the body, thus providing the energy for the body to physically escape the threat of injury to survive. Cortisol works in tandem with insulin from the pancreas to provide adequate glucose to the cells for energy. More energy is required when the body is under stress from any source, and cortisol is the hormone that makes this happens. In stressful situations, cortisol from stress allows the brain to think faster and the body to work longer and harder than at normal times. In cases of chronic stress, the body is inundated with cortisol from stress, and the effects to the body are damaging. In Adrenal Fatigue, more cortisol is secreted during the early stages. In later stages of Adrenal Fatigue (when the adrenal glands become exhausted), cortisol output is reduced.  How does this release of cortisol from stress effect you body and what can you do to manage the release of cortisol from stress to improve health?

Anti-inflammation Response

Cortisol is a powerful anti-inflammatory agent. When we have a minor injury or a muscle strain, our body’s inflammatory cascade is initiated, leading to swelling and redness are commonly seen when an ankle is sprained or when one gets an insect bite. Cortisol is secreted as part of the anti-inflammatory response, this is cortisol from stress. Its objective is to remove and prevent swelling and redness of nearly all tissues. These anti-inflammatory responses prevent mosquito bites from enlarging bronchial trees, eyes from swelling shut from allergies, and Adrenal Fatigue.

Immune System Suppression

People with high cortisol levels are very much weaker from the immunological point of view. Cortisol influences most cells that participate in the immune reaction, especially white blood cells. Cortisol suppresses white blood cells, natural killer cells, monocytes, macrophages, and mast cells. It also suppresses Adrenal Fatigue.


Cortisol contracts mid-size arteries. People with low cortisol (as in advanced stages of Adrenal Fatigue) have low blood pressures and reduced reactivity to other body agents that constrict blood vessels. Calcium, magnesium, and hormones such as angiotesnsin, aldosterone, norepinephrine, and adrenaline all moderate cortisol’s effect. The more circulation cortisol there is the more the mid-sized arteries contract. Cortisol also promotes the retention of sodium and keeps the heart contracting strong, both of which further enhance blood pressure. As a result, in the early stages of Adrenal Fatigue, blood pressure tends to rise as cortisol output is up. Along with other hormones that are released concurrently through various autonomic pathways, overall blood pressure tends to rise. As Adrenal Fatigue progresses to the more advanced stages, overall cortisol levels tend to fall, and artery contraction is reduced, resulting in low blood pressure and reduced reactivity to other body agents that constrict blood vessels. Sodium retention is reduced as cortisol output decreases. Sodium ion loss increases as aldosterone level is reduced. This is most prominent in adrenal exhaustion when low blood pressure, low sodium and low cortisol are hallmarks. This leads to reduced gluconeogenesis, rapid hypoglycemia, sodium loss, potassium retention, and thus, salt craving as the body cries out for more sodium as a compensatory mechanism. Low blood pressure that occurs during this time, along with hypoglycemia, can lead to body weakness, as the body needs sugar to generate energy. At the same time, electrolyte imbalance becomes more pronounced, resulting in cell crisis. Fortunately, cellular repair can be achieved if this viscous down cycle is arrested and the body is given the right nutrients to repair the damage.  So, what does this information mean to your every day and how are the effects of cortisol from stress impacting you regularly? Keep reading and learn more.

Steroids and cortisol from stressFacilitating the adrenals to normalize cortisol output, or managing cortisol from stress, is a major clinical goal of Adrenal Fatigue recovery. This is best done with natural compounds and not through steroid medication unless there is no other option. In fact, aggressive steroid therapy is a common mistake of Adrenal Fatigue recovery if not used properly due to its addictive and withdrawal issues, not to mention the many well-known side effects. One may use medication only if the case is very severe. Florinef is a synthetic salt-retaining steroid or mineral corticoid. It is frequently used in a setting of low cortisol and low aldosterone levels, requiring medical intervention. This prescription drug resembles very closely to aldosterone, the body’s salt-retaining steroid. A high-salt diet and high water intake is usually necessary for this drug to work well. Florinef forces the kidneys to retain sodium in exchange for potassium. As a result, the extracellular fluid volume increases, including blood volume. Blood pressure increases as “fluid weight” accumulates. Florinef tends to waste potassium, and periodic supervision by a physician with electrolyte monitoring is necessary.

Patients with severe autonomic failure should note that Florinef may worsen the high blood pressure when a person is in a supine position. This may lead to an increased chance of heart failure, stroke, or kidney decompensation. These risks have to be weighed against the benefit of prevention against fainting or falling from orthostatic hypotension.

Autonomic Nervous System

The nervous system of the body can be divided into the central nervous system, composed of the brain and the spinal cord, and the peripheral nervous system, which includes a part of the nervous system external to the central nervous system. The autonomic nervous system (ANS) is in turn composed of selected parts of both the central and the peripheral nervous system. It is the part of the nervous system that takes care of regulating the normal “housekeeping” functions of the body such as maintaining normal body temperature, heart rate, respiration, and blood pressure. It controls the smooth muscles and the glands inside our body. The ANS is in turn composed of multiple divisions. The key divisions governing blood pressure are the sympathetic nervous system (SNS) with norepinephrine as the messenger. SNS is also called sympathetic noradrenergic system for that reason. It determines the unconscious housekeeping process of the inner workings of the body. Another key division is the adrenomedullary hormone system (AHS) (also called sympathetic adrenergic system and are considered by some to be part of the SNS) with adrenaline as its messenger. AHS is activated and plays a critical role in guiding the body’s responses during distress and emergencies by increasing blood pressure, pulse rate, blood flow to skeletal muscles, and quiets the gut. Lastly, the parasympathetic nervous system (PNS) with acetylcholine as the main messenger acts as a balancer to the AHS and SNS. Activation of the PNS reduces heart rate, promotes urination and intestinal defecation. The ability of the body to regulate and maintain stable and normal blood pressure throughout the day requires a perfect balance of these three systems working in unison.

An increase of cortisol from stress is involved in the anxiety often associated with adrenal fatigueBecause maintaining normal blood pressure is essential for survival, the body has a built-in network of various information gathering, delivery and layers of control systems in place under the control of the brain. A tremendous array of sensors detects changes in levels of various chemical messengers throughout the body, providing information to the brain about heart filling, pressure, volume, and temperature. The brain also possesses sensors for serum osmolality, which along with chemoreceptors in the kidney, monitor concentrations of important electrolytes such as sodium. All these vital information are passed to effectors, which carry out the final regulation and fine-tuning of blood pressure. These effectors include the various components of the autonomic nervous system such as the SNS, AHS, and PNS mentioned above. In addition, they also involve the rennin-angiotensin-aldosterone system (RAS), insulin, growth hormone, hypothalamic-pituitary-adrenocortical axis (HPA), sympathetic cholinergic system (SCE), dopa-dopamine system, nitric oxide, and the thyroid gland. The final modulation of blood pressure, therefore, is highly complex involving the neurological, endocrine, and cardiovascular systems working in perfect synchronization in order to ensure a smooth internal homeostasis.

When we stand up, blood pressure drops. The SNS is activated immediately and blood pressure returns to normal within a short time. If low blood pressure is present due to low aldosterone or low cortisol, the SNS’ job is to return the blood pressure to normal as much as it can, or prevent it from dropping more. If the SNS fails to be activated, postural hypotension can develop. Imbalances of the various components within the SNS, in severe cases, can lead to fainting. Over-activation of the SNS, in particular, the AHS, can lead to heart palpitations, strong heart beats, anxiety, and cardiac arrhythmias.

The chemical messenger of AHS is adrenaline. Adrenaline is a far more potent messenger than norepinephrine. It relaxes skeletal muscle vessel, constricts skin blood vessels, increases heart rate, increases glucose in the blood, and increase respiratory rate. Its release from the adrenal medulla under AHS control often propels the body into a “flight or fight” response designed to enhance survival by delivering the much-needed blood and thus oxygen to vital organs such as the brain. Fainting, shock and fear all demonstrate physiologically the power of the AHS. Put it simply, AHS is so powerful it can shut the body down.

Dysregulation of the AHS can lead to high or low blood pressure. Imbalances can lead to postural hypotension, or orthostatic intolerance (OI). OI is a sudden drop in blood pressure when an individual stands up from a sitting, squatting or supine (lying) position. OI is a classic disorder of the autonomic nervous system. There are two forms of OI. The first kind is characterized by a sudden drop in blood pressure and a slow heart rate. This is the main cause of fainting. The second form of OI is characterized by an increase in heart rate heart with or without fainting. This is called postural orthostatic tachycardia syndrome (POTS).

Dysfunction of the ANS have comes in various forms. These can include overproduction or underproduction of chemical messengers, hyper or hyposensitivity of the chemical messenger’s receptor sites, premature or delay activation of the various systems within ANS and imbalances within he systems of the ANS. Consequences include symptoms such as fragile blood pressure, high blood pressure, orthostatic intolerance, low blood pressure, low pulse rate, fainting, and cardiac arrhythmias, anxiety, and a sense of being “wired and tired”.

Stress related illnesses and cortisol from stressDysfunction of the ANS itself is called dysautonomia. They can be primary or secondary. Symptoms can be clinical or sub-clinical. Both involve the mind and the body because every emotional a person feels include changes in somebody function through the ANS. It is, therefore, a “mind-body” disorder and misregulation of cortisol from stress only compiles it.

Frequently overlooked is the effect of sub-clinical primary dysautonomia’s harmful aggravation of other organ systems, or when dysautonomia is the consequence of other body system malfunction, such as Adrenal Fatigue. This is called secondary dysautonomia. Those with severe Adrenal Fatigue can present with symptoms resembling sub-clinical dysautonomia due to ANS dysregulation.

The association of ANS dysfunction and Adrenal Fatigue is strong. Most frequently, adrenaline overload seems to be the prominent clinical presentation. It is likely that such ANS dysfunction is triggered by AHS activation as a compensatory response to Adrenal Fatigue. Thus dysfunction of the ANS is secondary in nature. The exact mechanisms, however, are not known. Those with severe ANS imbalances without a significant history suggestive of Adrenal Fatigue need a complete workup to rule out primary dysautonomia. In particular, thyroid imbalances need to be ruled out.

Common symptoms of ANS dysfunction in an Adrenal Fatigue setting include faster than normal heart rate at rest, anxiety, feelings of being “wired”, strong heart rate, heart palpitation at rest especially in the middle of the night, fragile blood pressure, insomnia, dizziness, and a sense of low blood sugar. The body appears to be in a state of full alert. Sometimes these symptoms come in bursts, lasting minutes or hours, and spontaneously resolve in what is called “adrenaline rush.”

Resulting blood pressure is usually high. However, in case of Adrenal Fatigue where the body’s blood pressure is low, such as in adrenal exhaustion when the aldosterone and cortisol level are both low, the net blood pressure may be low, normal, high depending on the stage and severity of the intrinsic adrenal weakness.

Those with mild Adrenal Fatigue may see a normal to high blood pressure with fast heart rate. Those in adrenal exhaustion is likely to see normal to low blood pressure with a fast rate. Blood pressure in itself, therefore, cannot be an accurate gauge of the overall clinical picture without consideration of a detailed history and other accompanying symptoms. Unless a physician is alert and on a lookout, this connection is often missed, so it is important to communicate openly with your doctor about your stress so that she/he may assist you in proper management of cortisol from stress.

Successful recovery of the ANS dysfunction requires attention that needs to be paid not only to the ANS but also concurrently to the adrenals. When adrenal function normalizes, secondary ANS dysfunction often follows by improving itself.


The connection of blood pressure and Adrenal Fatigue cannot be over emphasized, nor can the value of managing cortisol from stress. Though blood pressure is usually normal or high in early Adrenal Fatigue, it usually gives way to low blood pressure as Adrenal Fatigue worsens. The more advanced the Adrenal Fatigue, the more prevalent symptoms of low blood pressure surfaces as well as a host of compensatory responses characteristic of adrenaline overload that is activated as part of a compensatory cascade. Such reactive adrenaline response includes dizziness, strong heart rate, irregular heart rate, lightheadedness, and postural intolerance. They affect the blood pressure as well.

Balancing cortisol from stress is essential to adrenal fatigue recovery

Low aldosterone, low cortisol, and dysfunctional autonomic nervous system are the three main reasons for many of these symptoms. Thus regulating cortisol from stress is critical to improving health conditions. Low aldosterone can often be overcome with diet adjustments such as salt intake.

Low cortisol can be supported by nutritional supplements designed to help the adrenals secret cortisol. Stimulants are to be avoided. If that fails, medications can be considered as last resort.

The autonomic nervous system (ANS) dysfunction is more complicated. Because it has both regulatory and compensatory role with mind-body connection, dysfunction of the ANS has a wide range of symptomatology. In an Adrenal Fatigue, setting dysfunction of the ANS is frequently tied to reactive adrenaline response with symptoms such as cardiac arrhythmia, anxiety, strong heart rate, low tolerance to temperature fluctuation and low fluid states, sense of impending doom, periodic bouts of “adrenaline rush”, fragile blood pressure, and a state of “wired and tired”. Healing the ANS without concurrent attention to the adrenal often fails. On the contrary, many with ANS dysfunction find stabilization once adrenal functions are normalized.  Keep in mind it always important to communicate with your health professional.  If you would like to manage your levels of cortisol from stress, then speak to your doctor to determine the best route for you.

Read Part 1

© Copyright 2013 Michael Lam, M.D. All Rights Reserved.

Dr. Lam’s Key Questions

The cortisol curve may take a long time to change in response to the amount stress that a person encounter. Some people with weaker constitution may have a switch in their cortisol curve earlier. The body has a feedback loop that automatically regulates and modulate cortisol over time to normal if given a chance.

When stress arrives, the brain sends out a signal through the HPA hormonal axis to reduce stress. The adrenal glands are activated to increase cortisol. Along with that, the autonomic system plays a big role in this response.

There can be metabolic reasons, such as sugar imbalances, as well as hormonal and neurotransmitter driven reasons too.

Cortisol from stress
5 -
Thanks for sharing this great article! It seems that science is now beginning to validate what a lot of us have known intuitively for a long time, in this case with the stress reducing benefits of listening to and playing music. Good to have this reminder.

Matthew Norrish


  • Sam says:

    In trying to advocate for myself, I ran across this article, and a number of things stuck out to me. I wondered if you could help point me in the right direction. For reference, I am a mostly healthy 32 year old female.
    In February, I experienced some sort of heart event that led to a 911 call and ambulance at my house. The paramedics found depressions on the EKG and high blood pressure. I was not transported, but followed up with my doctor a few weeks later. Nothing of note showed up on an in-office EKG, thyroid panel came back normal, and she ended the visit by saying that I seemed healthy but had high anxiety. Ever since then, I’ve been struggling with regular heart palpitations and extreme anxiety (with a couple full-blown panic attacks).
    When I think about the overall picture of my health, especially in reference to your article, a few things jump out. First, I have always had low blood pressure (80/50 range, and not much higher in pregnancy). Growing up, I got dizzy upon standing, but that hasn’t been a problem in years. My blood pressure has been going up lately in comparison to my normal baseline, but because it’s still in a normal range, no one but me thinks it’s odd. Second, I have been a lifelong nail/finger biter. Doesn’t seem like much, but has kept my system in a state of constant inflammation all of my life. That adds up, right? Also, over the past 2 years, I’ve become EXTREMELY sensitive to any sort of natural adrenaline rush. A tap on the brakes by the car in front of me can send me into a panic that takes several minutes to resolve. I’m unable to tolerate epinephrine at the dentist office. I’ve had to give up all sources of caffeine. For many years, I smoked marijuana, but had to stop because it induces anxiety. I was once a smoker and heavy drinker, but have not had any alcohol or tobacco in several years.
    All of this together makes me recognize that something is *off.* I plan on going to the doctor on Saturday and requesting a further checkup of my heart so I can let that go before addressing the anxiety. In light of the things I’ve mentioned, though, what other things would you suggest that I ask my doctor to check?

    • Dr.Lam says:

      Your doctor will go through routine check up, but chances are they will come back normal. If that is the case, you should look into AFS as possible root issue that may be contributing to your symptoms, as they certainly are not unusual in an AFS setting. We do see this type of clinical picture in advance stages of AFS where the body is on alert and kept on what is known as symptathetic overtone.
      Click Adrenal Exhaustion for more information.

      Dr Lam

  • Ken H Duffy says:

    In Aug 2014, my wife (73) was diagnosed with Iatrogenic Adrenal Insufficiency (inhaled steroids for 17 yrs, stopped May 2015), known in the UK as Secondary Addison’s Disease and was put on Hydrocortisone 17.5mg/day. She immediately exhibited serious Psychological deficit issues: loss of short term memory and mental acuity, confusion, mood swings and depression. She went on Dr Wilson’s adrenal repair regime for 4 months May 2015 and stopped Aug due to hospitalisation for pneumonia.
    Prior to adrenal repair regime, a Comprehensive Salivary Adrenal Stress profile was done by Genova Diagnostics which showed her 9 am Cortisol was only 0.2nmol/L, but with HC medication (12.5mg HC/day and steroids from inhalers), the rest of her results were ok following the diurnal rhythm—she continued to have the psychological issues. The results also showed that she was producing no DHEA—nothing was done about this!
    In April 2015 the test was run again but with no inhaled steroids and 10 mg of HC. There was little change in the results but of course this was quite an improvement.
    In Sept 2015 after the Dr Wilson regime was stopped, the 3rd test showed a significant improvement in the 9am level being nearly in the acceptance corridor at 4.69 nmol/L. However, all the other results showed a massive increase way above the normal range, indicating too much Cortisol, with the 1pm level at 110.36 nmol/L! The suggestion was that this may be Cushing’s—it’s generally accepted that my wife had Cushing’s before it progressed to Addison’s.
    The 4th test OCT 2015 now down to 7.5mg HC/day looked very promising with her 9am level in the green zone at 11.01 nmol/L, but the other three pm levels were still too high but lower than previous. DHEA had increased from .03 to .14 nmol/L. After this test 25mg/day DHEA supplement was administered mid Oct.
    Last test done Dec 2015 5mg HC/day. 9am level was slightly improved to 11.41, but other pm levels although lower than previous still too high. The DHEA level was off the chart at 3.47 nmol/L and the dose reduced to 12.5mg.

    There was a period of 5 days when my wife was fine on only 2.5mg HC/day, but this had to be increased as she had some serious spinal/neck nerve lesions affecting her right shoulder/arm/hand and fingers. She is still on treatment for this after 1 month.
    So the issue is, why are her 1pm, 5pm 10pm Cortisol levels so high on such a low dose of HC. It appears we have restored some natural Cortisol production but, this is not under the automatic control of the body with regard to stress. I have checked for Hypoglycaemia but her blood sugar levels are perfect.
    My wife also has AF and COPD and a host of other medical issues but not life threatening ones, e.g. high intraocular pressure, osteoporosis etc. After taking DHEA her mood swings have virtually gone and not as depressed. With reducing HC, her mental acuity has improved a little, is not as confused but short term memory is almost non existent. Her Neurologist has said this should return when she is completely off steroids—?

    • Dr.Lam says:

      your wife’s history is suggestive of a body that is very fragile, and that could account for the swings and turbulance that you are experiencing. Much more detailed history is needed for me to give you a full assessment. In general, you should be very careful with labs as often they do not provide the true and accurate picture. Its common to see swings that does not necessarily correspond with your medications and dosage. Your provider need to be able to think outside the box to make sense of it, and it does make sense if you look at the big picture. Learn to listen to your body is the key. Do not disregard your body’s quiet and gentle signals. Read Laboratory Testing for more information.

      Dr Lam

  • Cindy says:

    It’s been confirmed from my health history and 24-hr hormone testing (with flatline cortisol level) that I have Adrenal Fatigue stage 3C. Orthostatic hypotension has been confirmed as well. However, my BP is consistently bordering high at around 130/80. Is there an explanation for not having low BP with Adrenal Exhaustion? Are there other disorders that should be considered in addition to AF? All conventional medicine test done thus far have been unremarkable.

    Many thanks for your most informative articles.

    • Dr.Lam says:

      That is not unusual. We need to go more into your past history and the answer is generally there if you look hard enough. Labs alone is not going to be helpful once you have a mix picture like this. Remember you dont need 100% matching of all symptoms. Some people have more than others. The key is the big picture, and you need to be able to stand afar and look at what the body as a whole is telling you. This is where you need an experienced clinician as you may be confused easily and embark on the wrong track, so do be very careful.

      Dr Lam.