Recently I was asked by a thyroid patient whether I had an article on low cortisol symptoms.
As I discuss cortisol extensively in my books, I had not previously written a general blog post on the many symptoms arising from low cortisol, high cortisol, or aldosterone problems.
So, I have created this article based on a few extracts from Chapter 5 of my Thyroid Patient’s Manual book. Please see the book for a more complete description of the adrenal glands, adrenal hormones, and issues that can arise in connection with these.
Note: I am not going to discuss treatment options for low cortisol in this article. I do discuss this in my book The Thyroid Patient’s Manual. I also describe how to tackle low cortisol in my other two books, Recovering with T3 and The CT3M Handbook.
Low cortisol often goes hand in hand with thyroid problems, as it is often induced due to hypothyroidism, or incorrectly treated hypothyroidism.
This article will focus on the symptoms that can be caused by severe, moderate, or mild levels of low cortisol.
It will also briefly cover the symptoms of high cortisol and both low and high aldosterone.
People vary in the number of these symptoms that they experience and the severity of the symptoms.
Let me first cover the most severe type of low cortisol caused by adrenal gland failure (Addison’s disease).
Addison’s disease is a life-threatening condition. Proceeding with thyroid treatment without diagnosing and treating Addison’s disease could risk an Addisonian crisis and death.
In Addison’s disease, the adrenal cortices are destroyed. This is usually caused by an autoimmune attack. In this case, ACTH from the pituitary is not effective in producing sufficient cortisol.
Sufficient cortisol is required to maintain health and quality of life. In states of physiological stress, particularly caused by infection or physical exertion, the body produces significantly more cortisol – sometimes even by a factor of 10. Consequently, in Addison’s disease, the body cannot meet the demand for higher cortisol, and an Addisonian crisis can result, which can be life-threatening.
Sufficient aldosterone is required to maintain blood pressure and sodium/potassium balance. Many deaths from Addisonian crisis, or adrenal crisis, are caused by the nearly complete absence of aldosterone, which is necessary to maintain blood pressure and sodium/potassium levels and balance. Potassium levels become very high and can cause cardiac arrhythmias.
Note: in central adrenal insufficiency (little or no ACTH stimulation), the cortices will continue to produce sufficient aldosterone in most individuals. They will also produce a little cortisol – even with no ACTH secretion at all.
Addison’s disease is extremely serious and must be ruled out before proceeding with thyroid treatment if there is any evidence for it being present. To begin thyroid treatment in the presence of undiagnosed Addison’s would risk causing an Addisonian crisis. Addison’s disease symptoms usually develop slowly over many months.
The symptoms of Addision’s disease include:
- Extreme fatigue.
- Weight loss and decreased appetite.
- Darkening of your skin (hyperpigmentation).
- Low blood pressure, fainting, worse on standing.
- Salt craving.
- Low blood sugar (hypoglycaemia).
- Nausea, diarrhoea or vomiting.
- Abdominal pain.
- Muscle or joint pains.
- Low mood, mild depression.
- Body hair loss or sexual dysfunction.
- Frequent urination.
- Increased thirst.
If some or all of these symptoms are not responded to, the situation can worsen over time. These symptoms typically worsen when even a mild illness like a cold occurs.
Acute adrenal failure/Addisonian crisis symptoms:
- Pain in your lower back, abdomen or legs.
- Severe vomiting/diarrhoea.
- Low blood pressure, worse when standing up.
- Severe drowsiness or loss of consciousness.
- High potassium and low sodium.
- Muscle cramps.
- Severe dehydration.
- Pale, cold and clammy skin.
- Rapid, shallow breathing.
- Severe muscle weakness.
If the above is not promptly attended to, the risk of death through an Addisonian crisis is significantly higher.
Addison’s disease needs to be diagnosed and treated by an endocrinologist, as it can be life-threatening as I have said many times now. Extremely low cortisol in Addison’s disease is treated with hydrocortisone (HC), which is bio-identical cortisol.
Once on HC treatment, the individual needs to be aware that there are situations where a higher HC dosage needs to be used. The reason for this is that the HC an Addison’s patient requires will suppress any remaining ability to make cortisol. So, in the event of higher physiological stress, the body cannot respond to it by making more cortisol. The need has to be met by using more HC medication.
If your doctor suspects severe hypocortisolism, or adrenal gland damage or low aldosterone you need to be referred to an endocrinologist for further investigation.
Severe hypocortisolism may also prompt the doctor to consider low aldosterone as a possible problem, as this is often also present in Addison’s disease.
What about less severe low cortisol that is not caused by Addison’s disease?
Many thyroid patients experience milder levels of low cortisol, sometimes known as partial adrenal insufficiency, or adrenal fatigue. Both of these terms are misleading, as I will discuss soon.
Some of the symptoms of hypothyroidism may be confused with some of the symptoms of low cortisol since both can lower metabolic rate. Low cortisol may interfere with the conversion of T4 to T3 and result in lower FT3 and elevated rT3. Low cortisol also reduces T3-effect in the cells. When cortisol is low, blood sugar may also be low. Insufficient blood sugar will slow down the mitochondria – thus slowing down metabolism.
The mechanism that most frequently causes low cortisol is hypothalamic-pituitary (HP) dysfunction. This means that for some reason the HP system is not controlling one or more endocrine glands correctly, even though there may be no damage or disease in either the hypothalamus or pituitary.
Contrary to what many alternative medicine practitioners claim, the adrenal glands do not become ‘fatigued’ or ‘tired’. They can continue to make and secrete cortisol in large amounts as long as they are stimulated to do so by sufficient ACTH from the pituitary gland. For instance, cortisol levels remain very high indefinitely in Cushing’s disease – when a tumour produces excessive ACTH. So, even in the state of constant and prolonged excessive cortisol production, the adrenals just keep making cortisol. The adrenals can continue to make all the steroid hormones as long as there is sufficient cholesterol in the blood.
The rate-limiting step in cortisol production is the amount of ACTH-stimulation of the adrenal cortices. Hence, the terms ‘adrenal fatigue’ or ‘tired adrenals’ are misleading. The term ‘partial adrenal insufficiency’ tends to imply that the adrenals are ‘partially insufficient’. It is a vague term, but it is misleading too, as the adrenals themselves are usually not the issue.
The cause of most cases of low cortisol is inadequate secretion of ACTH by the HP system. It is a dysfunctional state, not a ‘disease’ state, i.e. there is usually nothing at all wrong with the adrenal glands themselves.
Often the cause of this HP dysfunction is unknown, although many studies have shown that it can result from extreme or prolonged stress. The net effect of this is that cortisol and DHEA eventually fall. Dysfunction of the hypothalamic-pituitary-adrenal axis (HPA axis) is thought by some doctors to be the number 1 cause of low cortisol problems.
Genetic mutations can also cause adrenal cortex dysfunction. Mutations can reduce the function of the enzymes needed to make cortisol, resulting in a condition known as congenital adrenal hyperplasia (CAH). Milder versions of this disorder occur in adults – where it is known as non-classical CAH. In CAH, DHEAS levels are high as more ACTH is secreted to super- stimulate the cortices to make enough cortisol.
Mild to moderate low cortisol problems are far more common than the severe cortisol insufficiency of Addison’s disease. Unfortunately, most doctors do not test, recognise, or treat moderate to mild low cortisol.
I prefer to use the term ‘hypocortisolism’ versus ‘low cortisol’. Low cortisol is better defined as the sub-optimal effect of cortisol within some or all of the cells. This definition includes all the possible causes, e.g. HP dysfunction, adrenal gland disease, and even cortisol resistance. It includes everything that stops cortisol from optimally operating within the cells. Consequently, I use the terms hypocortisolism and low aldosterone – which are far more specific.
Some of the main symptoms of hypocortisolism include:
- Low blood sugar – dizziness, unwell, hunger.
- Severe fatigue, tiredness.
- Dizziness (even when sitting down).
- Low blood pressure.
- Intolerance to even low dose thyroid medication.
- Poor response to thyroid treatment or dose raises.
- Anxiety or inability to cope with stress.
- Irritability or anger or panic feelings.
- Feeling cold/low body temperature.
- Fluctuating body temperature.
- Aches and pains.
- Pale skin or slight darkening of the skin.
- Skin appears thinner.
- Digestive upsets – may include diarrhoea.
- Weight loss if cortisol very low.
- Worsening allergies.
- Trembling, shakiness or jittery/hyper feeling.
- Rapid heartbeat especially after thyroid meds.
- Difficulty sleeping.
- Flu-like symptoms.
- Dark rings under the eyes.
- Low back pain (where adrenal glands are).
- Worsening symptoms in presence of stress.
- Fatigue in the morning but better in the evening.
Some of the main symptoms of low aldosterone include:
- Low blood pressure.
- Postural hypotension (lower BP on standing).
- Craving for salty foods.
- Light headedness on standing.
- Frequent urination (esp. during the night).
- Excessive sweating.
- Slightly higher body temperature than usual.
- High heart rate/palpitations.
- Cognitive fuzziness.
- Dizziness or fainting.
- Low sodium and high potassium.
Note: low aldosterone can occur with or without Addison’s disease. It can also occur with or without hypocortisolism. So, your doctor should be aware of this and be on the lookout for any tell tale indications of it, even if you do not have Addison’s disease.
Low levels of thyroid hormone can cause several symptoms of hypocortisolism
This can obviously make recognising hypocortisolism a bit of a challenge. If someone has been hypothyroid for a considerable time before diagnosis and treatment, it is possible that there will be hypocortisolism present. Therefore, hypocortisolism is something that a family doctor or endocrinologist should either check for, or at the very least, be on the lookout for.
Let me now briefly discuss high cortisol.
These are some of the clues when high cortisol is present:
- High blood pressure.
- Vasoconstriction which can causes pains/twinges in the chest.
- Bruising easily.
- Fluid retention.
- Weight gain, obesity, or moon-shaped face.
- Increased belly fat, fat on back of the neck.
- Weak muscles and muscle loss.
- Facial flushing.
- Bile acid indigestion – burning in stomach.
- Mood swings – anxiety, depression, irritability.
- Reduced TSH.
- Reduced FT3, increased rT3.
These are some of the clues when high aldosterone is present:
- High blood pressure.
- Low potassium (weakness/muscle spasms).
- Numbness or tingling in the extremities.
- Frequent urination.
Please ask your doctor to run lab tests for cortisol and/or aldosterone if you suspect excess adrenal hormones.
For a more full description of the adrenal glands, adrenal hormones, disease states, and treatment options please see The Thyroid Patient’s Manual book.
This blog post now complements one that I did in March 2020 which covers the symptoms of hypothyroidism. Together these two articles provide good information on the symptoms of both types of conditions: