Cortisol is known as the “stress hormone,” and ironically, online discussions and videos about cortisol imbalance seem to stress people out. That includes me: I have anxiety and, as a result, I’ve always wondered about how my stress is affecting my cortisol levels. I finally got the opportunity to find out when Quest, a diagnostic information services provider, offered me a complimentary Cortisol Blood Stress Hormone Test.
Following my cortisol blood test, I’ve spoken with several doctors to better understand my “high cortisol” results and answer the question: Should we all be concerned about cortisol? Or are all these videos on social media stressing us out for no reason?
What is cortisol? Does it control stress?
“Cortisol is an essential hormone produced and released by adrenal glands,” said Dr. Sanjay Dixit, medical director of cardiometabolic endocrine and wellness solutions at Quest Diagnostics and medical expert for questhealth.com, in an email. “Many people associate cortisol as being the ‘stress hormone,’ but it actually has many additional important functions.”
In addition to managing the body’s response to stress, cortisol regulates blood sugar and blood pressure, the sleep-wake cycle and metabolism while suppressing inflammation.
“It is most commonly known as the ‘stress hormone’ because it’s released in response to stress and works to prepare the body for ‘fight-or-flight,'” added Dr. Sajad Zalzala, co-founder and chief medical officer of longevity platform AgelessRx, via email. “It increases glucose availability, which supplies energy and mobilizes stored fats and proteins to provide additional fuel.”
Do you need a cortisol blood test?
Dr. Dixit explained that someone could get a cortisol test to see if they have a cortisol deficiency, also known as adrenal insufficiency. Symptoms of this can include:
- Fatigue or being overly tired
- Worsening muscle weakness
- Skin changes (particularly darkening in folds and scars)
- Loss of appetite
- Unintentional weight loss
- Low blood pressure
Another reason a cortisol test may be ordered is to see if a patient has excess cortisol, generally known as Cushing’s syndrome. Potential symptoms for this include:
- Bruising easily
- Unintentional weight gain
- Muscle weakness
- Fatigue
- Rounded and rosy face
- Increased fat in the upper back
- Impaired glucose tolerance
“[Impaired glucose tolerance is] something that can be particularly noticeable in type 2 diabetic patients who have trouble managing their glucose levels even with adherence to prescribed medication,” said Dr. Dixit.
What happens during a cortisol blood test?
Before my blood was drawn for this test, I had my yearly physical with my primary care provider. I notified her that I would be getting this test and asked to have my other preventative blood tests taken simultaneously. I want to mention this because it’s important to run any health-related tests by a doctor who knows you and your health history.
According to Quest, you must be at least age 18 to buy a test, which is unavailable in Alaska, Arizona or Hawaii. For select tests, you will be asked to answer relevant medical questions. Before a test order is submitted for processing, your purchase and answers will then be reviewed by a telemedicine doctor affiliated with the national clinician network PWNHealth to ensure this test is medically appropriate for you.
You must also schedule the cortisol test between 7 a.m. and 9 a.m. “Cortisol levels naturally change throughout the day,” Quest answered in an FAQ, stating that since cortisol levels usually peak in the morning, this particular level would be the best indicator of a cortisol problem.
No fasting is required. But I had to fast for the other blood tests ordered by my doctor.
According to Dr. Dixit, it is also important to note that “a blood test for cortisol can be inaccurate in some cases.” Inaccurate results, for example, can happen if a person is taking oral contraceptives or steroids, such as prednisone.
Once I bought the cortisol test on Quest’s website — it ordinarily costs $89 with a $6 physician service fee — I was sent an email with my order number and a link to schedule an appointment at a nearby Quest location. I scheduled my appointment for 8:20 a.m. at the facility closest to me.
On the day of my appointment, I was texted a link to check in when I arrived and was admitted within 5 minutes. (I highly recommend scheduling beforehand so you don’t have to wait.) I get particularly anxious about blood tests, so I notified my technician and asked if I could lie on an exam table. She assured me that many people get nervous about blood tests and, after I signed off on my tests, did a great job talking to me as a distraction while my blood was drawn.
Later that night, I received the results of my cortisol test. As for the results from the tests ordered by my doctor, I received them five days later. Quest reports that processing times vary, but it generally takes up to eight business days to receive results.
My cortisol blood test results
Unsurprisingly, my cortisol blood test results came back as “high” at 33.2 mcg/dL. Quest reports that a normal range between 7 a.m. and 9 a.m. is 4.0-22.0 mcg/dL. To be frank, this freaked me out. I had a feeling that my cortisol levels would be high because of my general anxiety and heightened nerves around blood tests, but actually seeing that “high” result and not fully understanding it ironically increased my stress levels even more.
Quest allows you to discuss your results with an independent physician, so I took advantage of this offer. I called Quest’s customer service line and was emailed to schedule my appointment with a physician at PWNHealth via Everly Health Solutions, a digital health company that acquired PWNHealth in 2021. When scheduling my appointment, I provided context about my cortisol blood test. I was then told that a physician would call me within 4 hours during business hours.
Within 4 hours, a PWNHealth physician called. I asked the doctor if my cortisol level was in line with the fact that I have anxiety and was stressed about the blood test. She said that it could be why my cortisol was acutely high, but that chronically high cortisol levels could be concerning and caused by other conditions, certain medications or pregnancy. She added that it could be related to an adrenal gland condition.
I also asked about how high cortisol levels can go and she stated that there is no “highest point,” especially since it varies from person to person, depending on the condition. She added that people with adrenal gland conditions typically show higher cortisol levels, but there isn’t a specific cutoff.
Though the doctor stated that my high cortisol was likely due to anxiety, she recommended that I follow up with my primary care physician. Afterward, I was able to download my Quest results as a PDF and send them to my PCP.
What are ‘normal’ cortisol levels? Why do they change?
“The ‘normal’ reference range varies slightly with the lab that’s doing the testing,” said Dr. Zalzala. “Quest reports a normal a.m. (7 to 9 a.m.) blood level of 4.0 to 22.0 mcg/dL, whereas Labcorp reports normal a.m. blood level of 6.2 to 19.4 mcg/dL.”
As for why cortisol varies throughout the day: “Cortisol is very important in helping a person transition from sleep to wakefulness,” Dr. Zalzala explained. “This triggers a ‘morning cortisol surge’ — a rapid rise in cortisol levels within 20 to 30 minutes of waking, which jumpstarts alertness and prepares the body for the day.”
Over the course of the day, our bodies will also experience mini peaks in cortisol levels to help us maintain energy and alertness. These peaks typically occur around noon and in the early evening. “Interestingly, these peaks often align with standard meal times, playing a key role in supporting our body’s ability to metabolize food and regulate energy levels,” said Dr. Zalzala.
Dr. Betul Hatipoglu, MD, professor of medicine at Case Western Reserve University’s School of Medicine and medical director of the Diabetes and Metabolic Center at the University Hospital Cleveland Medical Center, stated in an email that there is a “normal, what we call ‘circadian rhythm’ for cortisol.” As the day goes on, cortisol levels will gradually decrease and become lowest closer to bedtime.
How high can cortisol levels go?
“Cortisol levels could go as high as or closer to 40 [mcg/dL] in individuals who are extremely ill, such as people in intensive care,” Dr. Hatipoglu said. Dr. Zalzala added that a normal adult can generate cortisol levels up to 50 mcg/dL, which is about two to three times their morning surge level, during times of stress.
Dr. Zalzala also mentioned Cushing’s syndrome, a rare disorder in which “the adrenal gland starts making cortisol on its own (adrenal tumor) or in response to a pituitary gland tumor that makes too much ACTH [adrenocorticotropic hormone, which regulates cortisol] and ignores the feedback cycle.” For those with this disorder, cortisol levels can go as high as 100 mcg/dL.
In cases where someone is extremely ill, such as with septic shock, Dr. Zalzala stated that levels can be as high as 1,000 mcg/dL.
The relationship between cortisol and anxiety
I shared my results with all the doctors I consulted to see if I could get a better understanding of how anxiety could affect my cortisol levels — and any other factors that may be at play.
“High cortisol in a normal individual can be a sign of stress in your case,” said Dr. Hatipoglu. “However, sometimes other hormones can affect the cortisol levels. For example, if someone is taking oral contraceptives or estrogen therapy, this can increase total cholesterol, which is what you have been tested for.”
Due to fasting, anxiety and being stressed about my blood draw, Dr. Zalzala said that combination could have caused my morning cortisol level to be higher than normal. He added, “Studies have shown that stress or acute anxiety can drive cortisol levels significantly higher, often to values similar to what you experienced.”
Do doctors recommend a cortisol blood test? What other cortisol tests are there?
“I usually would check a random cortisol before 9 a.m. in the morning to make sure the level is not low,” said Dr. Hatipoglu. “If we are concerned about high cortisol, it is usually recommended that we actually do different evaluations.”
To understand whether elevated cortisol levels are a normal reaction or an abnormal increase, Dr. Hatipoglu may then want to do testing such as a milligram dexamethasone suppression test (which measures whether cortisol secretion by the adrenal gland can be suppressed) or a 24-hour urine cortisol test (which measures the amount of cortisol in a person’s urine over a day). However, if a patient is on birth control, stopping it for a few months and then repeating the cortisol test may help show their body’s actual cortisol levels.
Dr. Zalzala, on the other hand, stated that he rarely recommends a single morning cortisol test unless a patient is believed to have Addison’s or Cushing’s disease. Addison’s is a rare endocrine disorder caused by damaged adrenal glands that can’t produce enough hormones.
“For those people who want to use cortisol levels as a tool to make lifestyle adjustments and to monitor other interventions (like therapy or sleep medications), then the saliva cortisol level is the one I would recommend,” stated Dr. Zalzala. “Studies indicate that salivary cortisol levels show a reasonably strong correlation with serum cortisol.”
For my “high” result specifically, Dr. Zalzala stated, “While this result aligns with the stress factors you’ve described, cortisol levels above 20–25 µg/dL [which is the same as mcg/dL] in the morning can sometimes prompt further evaluation, particularly if symptoms suggest additional hormonal imbalance.”
If I were to take supplementary tests under less stressful conditions and my cortisol continues to be elevated, Dr. Zalzala said I should explore other factors with my healthcare provider. “They may consider repeating the test using alternative methods, like a 24-hour urinary free cortisol or late-night salivary cortisol test, which are less affected by immediate stress responses.”
While this particular cortisol blood stress hormone test can be a good first step, Dr. Dixit acknowledges that it may not necessarily be the last one. He suggested that a person concerned about their health should talk to their doctor — even if the test results don’t show anything wrong.
What happens if a cortisol blood test is abnormal?
“I think the best way here would be to see a physician, a nurse practitioner or a healthcare provider to get an evaluation,” Dr. Hatipoglu said. “[This is] done to understand if it is true [cortisol] elevation or is it stress-induced.”
Dr. Dixit specifically recommended that in addition to a primary healthcare provider, one could see an endocrinologist, a doctor specializing in diagnosing and treating health conditions that affect the endocrine system. “That’s because testing for excess cortisol is not as straightforward as a single blood test,” he said, adding that a healthcare provider could perform an evaluation, recommend additional tests and consider other potential causes.
However, if additional tests remain abnormal, a trained clinician must be consulted for further diagnostic decisions. “Most conventionally trained physicians would initially evaluate for Cushing’s or Addison’s disease,” Dr. Zalzala said. “If these are ruled out, a thorough clinician would then investigate other contributing factors affecting cortisol levels. Conversely, a less attentive approach might dismiss the patient without addressing the underlying issues.”
If a doctor does determine that there are problems with excess cortisol or adrenal insufficiency, Dr. Dixit stated that the methods used to address the issue depend on the root cause. For example, with Cushing’s syndrome, medication or surgery may be required since the disorder can be caused by a tumor on the adrenal or pituitary glands.
What can cause abnormal cortisol levels?
“I think it’s useful to talk about the ways the normal cortisol cycle can be disrupted, that could show up on salivary testing if done at the right times of day,” said Dr. Zalzala, who listed the following as common causes for a disrupted cortisol cycle:
- For cortisol levels that remain low and flat throughout the day: chronic stress, adrenal fatigue, burnout and some chronic inflammatory conditions
- For lower morning cortisol levels that then peak in the evening: chronic stress, sleep disorders, shift work and certain mental health conditions (for example, PTSD)
- For normal morning cortisol levels that increase in the evening: anxiety, high-stress lifestyle, evening exposure to artificial light (such as from screens) and late-day caffeine or high-stress activities
- For a lower or absent rise in cortisol upon waking, or Cortisol Awakening Response): chronic stress, depression, PTSD, burnout and shift work
Symptoms of high cortisol or cortisol deficiency can also be connected to non-cortisol-related conditions and health issues, according to Dr. Dixit. That is why consulting a doctor about your results and symptoms is essential.
Abnormal cortisol health impacts
While social media may oversimplify all things cortisol as a means of clickbait, Dr. Zalzala said it should not be dismissed. That’s because dysregulated cortisol has the following long-term health impacts:
- Mental health issues such as anxiety, depression and mood instability
- Cognitive impairment such as memory problems and impaired executive function
- Metabolic disorders that involve weight gain and obesity, insulin resistance, increased risk of metabolic syndrome and type 2 diabetes and blood sugar instability (such as hypoglycemia or hyperglycemia)
- Cardiovascular issues like hypertension, arterial stiffness, inflammation and heart disease, raising the risk of heart attacks and stroke
- Immune system impairment that can include increased susceptibility to infections and autoimmune conditions such as rheumatoid arthritis or lupus
- Bone health issues and muscle wasting like osteoporosis and muscle loss
- Sleep disruption and fatigue, including insomnia, chronic fatigue, low motivation and difficulty managing stress
- Digestive issues such as gastrointestinal inflammation contributing to conditions like irritable bowel syndrome (IBS) and exacerbating symptoms of inflammatory bowel diseases like Crohn’s disease, and gastric ulcers
Should people be concerned about their cortisol levels?
The question that’s on everyone’s mind. After mentioning all of the social media videos circulating saying that people should be worried about their cortisol levels, I asked doctors if there is any legitimacy to these claims or if it’s just fearmongering.
“I don’t think it is fair to say people should be concerned about their cortisol levels — as you can see, cortisol constantly fluctuates,” said Dr. Hatipoglu. “The fluctuation occurs so many times that it is sometimes even difficult to know what is very normal or very abnormal.” However, if you are concerned about your cortisol, she recommends seeing a doctor to see if a test is needed first instead of having it tested randomly.
While Dr. Zalzala acknowledges that there is some truth to the concept of “minding your cortisol levels,” since there are medical conditions that can cause abnormal cortisol levels, he believes “social media often oversimplifies this, turning cortisol into a scapegoat for various health issues.” He specifies that cortisol imbalances are typically caused by deeper issues such as poor sleep, unhealthy habits, unmanaged stress and substance abuse, in which case “cortisol is more of a symptom than the root cause.”
“Cortisol levels, as a tool, should be used in conjunction with other tools like a CGM sensor or a sleep monitor,” concluded Dr. Zalzala.
How to naturally reduce cortisol with lifestyle changes
“I usually recommend important, basic lifestyle management, [including] nutritious meals and good nutrition; movement exercise like yoga, walking and swimming; a good night’s sleep, meditation and mindfulness; good vitamin D; and stress management for day-to-day stresses of life,” said Dr. Hatipoglu. “And last, as much as possible, eliminating smoking and excess alcohol.”
“Minimize caffeine and sugar intake, especially later in the day,” Dr. Zalzala recommended. “Both can elevate cortisol and disrupt the normal rhythm, making it harder to wind down at night.” Excess sugar and starch can cause a spike in blood sugar followed by a crash. This can occur in the middle of the night, disrupting your sleep.
If you maintain a consistent sleep schedule and evening routine without screen time or intense exercise (which can elevate cortisol and disrupt sleep) but still struggle to fall asleep, Dr. Zalzala recommends mild sleep aids like melatonin or L-theanine before moving on to strong options like passionflower or California poppy. “If these aren’t effective, consult a doctor about medications like trazodone or doxepin and rule out conditions like sleep apnea,” he said. “Always discuss sleep therapies, including OTC supplements, with a doctor.”
The takeaway
While the results of my cortisol blood test did stress me out, I’m glad I tried it because it helped me learn more about cortisol. It also gives me even more of an incentive to increase my stress and anxiety management. While I’ve always prioritized my health and wellness, since getting the cortisol blood test, I’ve started exercising more than before, going to bed earlier, thinking up new ways to lower my stress levels and paying closer attention to having a well-balanced diet.
As for ordering the test through Quest, I thought the process was smooth, and it’s nice to have control over the health tests you can get done (if approved, of course). I also appreciated having the option to speak with an independent physician about my results. However, as both Quest and the doctors I consulted advised, it is best to do any health tests under the supervision of a healthcare provider, who can then help with diagnosis and potential treatment. I’m glad I told my doctor about the test and that it was easy to send her my results. And now, I’m way more informed about what the next steps could be if further testing is needed.
