Clinical

A Quick Reference Guide to Conditions Related to Cortisol

Osmosis Team
Published on Feb 1, 2024. Updated on Jan 29, 2024.

Introduction

A common topic of discussion in the media, cortisol has been an ongoing focus for researchers due to the major impact it has on our health. Disrupting cortisol levels can lead to a variety of health issues, ranging from complications with the adrenal and pituitary glands to the negative effects of using certain medications for a long period. Cortisol also affects our mental health, with studies suggesting links between elevated levels of cortisol and anxiety and depression. It also plays a role in our metabolism, immune function, and circadian rhythm regulation, with studies underway on the effects of chronic cortisol exposure and increased risk of chronic conditions such as cardiovascular issues, metabolic disorders, and immune system dysfunction.

A steroid hormone produced by the adrenal glands, cortisol plays a vital role in a variety of functions within the body, such as helping maintain blood pressure, regulating glucose metabolism, reducing inflammation, and mediating stress. The hypothalamic-pituitary-adrenal (HPA) axis manages cortisol within a narrow range to support these functions. Specifically, the hypothalamus releases corticotropin-releasing hormone (CRH) to stimulate the anterior pituitary gland to release adrenocorticotropic hormone (ACTH), which then triggers the adrenal glands to produce cortisol. In some cases, there’s either too much or too little cortisol in the body due to dysfunction along the HPA axis. Let’s take a closer look at some conditions related to cortisol levels. 


Hypercortisolism

Excess cortisol, also called hypercortisolism, is when there are high levels of the hormone cortisol in the body due to exogenous or endogenous causes. The most common cause of exogenous Cushing syndrome is the chronic use or high doses of exogenous glucocorticoids (e.g., prednisone, hydrocortisone, dexamethasone). This excess cortisol can be caused by adrenal hyperplasia, a hormone-secreting tumor on the adrenal glands, or even a tumor in other places in the body, like the lungs, that secretes ACTH. When a pituitary adenoma causes the pituitary gland to secrete excess ACTH, it results in a type of Cushing syndrome called Cushing disease.  

Regardless of the cause, signs and symptoms of hypercortisolism are typically nonspecific and include weight gain with a central distribution (truncal obesity), hair loss, decreased libido, fatigue, and weakness. Other manifestations can include elevated blood pressure and blood glucose, menstrual changes, cutaneous atrophy, and erectile dysfunction. There are also typical facies (facial expressions or a type of appearance) associated with hypercortisolism, including a round face (i.e., moon face); facial flushing; dorsocervical fat pad (i.e., “buffalo hump”); and fat pads above the clavicle (i.e., supraclavicular fat). 

Diagnosis of hypercortisolism is based on a medical history, physical examination, lab testing, and diagnostic imaging. Lab testing can include cortisol levels (e.g., serum, urine), ACTH levels, and dexamethasone suppression tests. Diagnostic imaging, like a brain MRI and adrenal gland CT, can help determine the underlying cause (e.g., pituitary adenoma or adrenal hyperplasia, respectively).

Treatment of hypercortisolism depends on the underlying cause. In cases related to glucocorticoid use, gradual withdrawal of the medication can be done. For tumors, surgical resection may be required and can be followed with radiotherapy or certain medications, if necessary.



Hypocortisolism

Conversely, hypocortisolism, also called adrenal insufficiency, is when there are low levels of cortisol in the body, and it can be primary, secondary, or tertiary. Primary adrenal insufficiency, also called Addison disease, occurs when the adrenal glands can’t produce cortisol; secondary adrenal insufficiency occurs when the pituitary gland does not release enough ACTH; and tertiary occurs when the hypothalamus does not release enough CRH. 

Similar to hypercortisolism, adrenal insufficiency can present with nonspecific symptoms, including weight loss, fatigue, hair loss, menstrual changes, and decreased libido. Other manifestations include skin changes (e.g., hyperpigmentation, decreased turgor), altered mental status, or psychiatric changes. In severe cases, an acute adrenal crisis may occur, which is a medical emergency presenting as shock (e.g., hypotension, confusion, abdominal pain, altered level of consciousness).  

Diagnosis of adrenal insufficiency is made through medical history, physical examination, and lab testing. Lab testing can include serum levels of cortisol, ACTH, renin, and aldosterone; complete metabolic panel; anti-21-hydroxylase antibodies; and tests looking for infectious causes (e.g., tuberculosis). An ACTH stimulation test may also be done. 

Treatment involves stabilizing an individual if they’re presenting in acute adrenal crisis, identifying any underlying cause, and providing supplemental cortisol (e.g., hydrocortisone, prednisone, dexamethasone), typically required for life. 

Explore other common conditions:

A Quick Reference Guide to Common Conditions in Older Adults

A Quick Reference Guide to Common Conditions Associated With Pregnancy

A Quick Reference Guide to Common Conditions Associated with Gut Health

About the Author

Kelsey LaFayette, DNP, ARNP, FNP-C, Nursing Content Manager at Osmosis from Elsevier, obtained a Bachelor of Arts in Nursing degree from Luther College in 2011. As an RN, she has a clinical background in medical and pulmonary inpatient units, urgent care, and critical care, and obtained her Doctor of Nursing Practice degree at the University of Illinois at Chicago in 2022. Throughout her career, Kelsey has had many opportunities to function in an education role by being a charge nurse, preceptor to new RNs and nursing students, as well as a Clinical Team Lead in charge of creating orientation programs and policies. Through these opportunities, Kelsey realized her ideal career path should focus on the education of nurses, nursing students, patients, families, and anyone else with a desire to learn. Kelsey serves as a manager on the Nursing Content team and has been able to work on various projects that fulfill her love of perpetual learning.

Reviewer

Lisa Miklush, PhD, RN, CNS, Senior Content Editor

References

Ceccato F, Scaroni C. Central adrenal insufficiency: open issues regarding diagnosis and glucocorticoid treatment. Clin Chem Lab Med. 2019;57(8):1125-1135. doi:10.1515/cclm-2018-0824 

Cole S. Evaluation and treatment of adrenal dysfunction in the primary care environment. Nurs Clin North Am. 2018;53(3):385-394. doi:10.1016/j.cnur.2018.04.007

Hirsch D, Shimon I, Manisterski Y, et al. Cushing's syndrome: comparison between Cushing's disease and adrenal Cushing's. Endocrine. 2018;62(3):712-720. doi:10.1007/s12020-018-1709-y

Martin-Grace J, Dineen R, Sherlock M, Thompson CJ. Adrenal insufficiency: physiology, clinical presentation and diagnostic challenges. Clin Chim Acta. 2020;505:78-91. doi:10.1016/j.cca.2020.01.029

Nieman LK. Recent Updates on the diagnosis and management of Cushing's syndrome. Endocrinol Metab (Seoul). 2018;33(2):139-146. doi:10.3803/EnM.2018.33.2.139

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8584322/

https://www.nature.com/articles/s44220-023-00016-0