Stress, Menopause & the Cortisol Connection

Where is the intersection of fatigue, meets menopause, meets stress?

How do I know if it’s due to changes in estrogen or excess stress causing the multitude of symptoms: fatigue, insomnia, weight gain, depression, anxiety? The truth is that stress can be the number one saboteur of our healthy lifestyles. It may not matter how well we eat or exercise if our stress and subsequent stress response, cortisol, is out of control. But it is more complicated for women in perimenopause and menopause than just blaming it all on stress. 

Let’s look at the basics of cortisol, our stress response and effects menopause has on all of the above. 

Cortisol is a hormone that is produced by the adrenal glands and plays a vital role in the body's stress response. Cortisol levels naturally fluctuate throughout the day, with the highest levels in the morning and the lowest levels at night. In the morning, cortisol levels rise rapidly in response to the body's natural circadian rhythm, which helps to increase alertness and energy levels to prepare for the day ahead. This is commonly known as the "cortisol awakening response" and occurs within the first 30 minutes after waking up.

Throughout the day, cortisol levels typically continue to decrease, reaching their lowest levels in the late evening and early night. This natural decrease in cortisol levels helps to promote relaxation and prepare the body for sleep.

However, cortisol levels can also fluctuate in response to stressors throughout the day. When the body is under stress, cortisol levels can rapidly increase, which helps to provide the energy needed to respond to the stressor by increasing blood sugar levels, suppressing the immune system and decreasing inflammation. This is commonly known as the "fight or flight" response and is a natural and necessary response to stress.

In addition to regulating the,  sleep-wake cycle, cortisol also plays a role maintaining blood pressure, and controlling metabolism.

Cortisol maintains blood pressure is by increasing the responsiveness of blood vessels to vasoconstrictors, such as norepinephrine. This causes the blood vessels to narrow, which increases blood pressure. Cortisol also increases the production of angiotensin II, a hormone that causes blood vessels to constrict and increases blood pressure.

Cortisol provides energy to the body by stimulating the liver to produce glucose, which is released into the bloodstream to provide energy for the body. This is important during times of stress when the body needs extra energy to cope with the stressor. Cortisol can also stimulates the breakdown of fats and proteins to provide energy for the body.

During perimenopause and menopause, cortisol levels can become imbalanced. This is due, in part, to the decline in estrogen levels that occurs during these stages. Estrogen helps regulate cortisol levels at the HPA axis or hypothalamic-pituitary-adrenal axis as well as regulating an enzyme involved in cortisol production. When estrogen levels decline, cortisol levels can become dysregulated, meaning they may be higher or lower than normally expected at various times of the day.

One of the most common symptoms of cortisol dysregulation in perimenopause and menopause is insomnia. Insomnia is a sleep disorder that is characterized by difficulty falling asleep, staying asleep, or waking up too early. Ever find yourself all of a sudden awake around 2am needing to use the bathroom? A spike in our cortisol causes the awakening. Typically  cortisol levels are highest in the morning and decrease throughout the day, but in perimenopause and menopause, cortisol levels may shift, causing  increased cortisol levels at night. This can disrupt the sleep-wake cycle, making it difficult to fall asleep and stay asleep.

Cortisol dysregulation can also lead to other symptoms, such as anxiety, depression, and irritability. High cortisol levels can cause anxiety and irritability, while low cortisol levels can cause depression and fatigue. In addition, excess cortisol can contribute to weight gain, especially around the abdomen. This is because cortisol can increase insulin resistance, which can lead to an increase in belly fat.

In addition to the physical symptoms, cortisol imbalance can have long-term effects on a woman's health. Chronic stress and prolonged elevated cortisol have been linked to an increased risk of cardiovascular disease, diabetes, and osteoporosis as well as decreased immune function and increased inflammation.

Now that you have an understanding of what cortisol is and how it works in the body, you may be wondering how to impact excess cortisol or alterations in the circadian rhythm that has you up all night. 

There are several natural methods that can help reduce cortisol levels or return cortisol to its natural rhythm:

1. Exercise: Regular exercise can help reduce cortisol levels and improve mood. Aim for at least 30 minutes of moderate exercise most days of the week. If you are new to exercise considering adding more walking to your day, aiming for 10,000 - 12,000 steps on most days of the week.
2. Mind-body practices: Practices such as yoga, tai chi, and meditation have been shown to reduce cortisol levels and promote relaxation.
3. Healthy diet: Eating a balanced diet with plenty of fruits, vegetables, and whole grains can help reduce inflammation and stress on the body, which can help regulate cortisol levels. Increasing the amount of vegetables and fruits you consume daily will also increase your fiber intake naturally, assisting with overall reduction of stress on the body. 
4. Limit caffeine and alcohol: Caffeine and alcohol can both disrupt cortisol levels and should be consumed in moderation or avoided altogether. 
5. Social support: Having a strong support system of family and friends can help reduce stress and improve overall well-being.
6. Stress management techniques: Techniques such as deep breathing, visualization, and progressive muscle relaxation can help reduce stress and promote relaxation.
7. Adequate, quality sleep: Getting enough sleep is crucial for maintaining healthy cortisol levels. Aim for 7-9 hours of sleep each night. I know this is a tough one for those of us in perimenopause and may seem impossible. Focusing on the other 6 methods may actually assist your sleep naturally without additional effort.

Overall, cortisol plays a critical role in the body's stress response and natural circadian rhythm, and it is important to maintain healthy cortisol levels throughout the day through stress management techniques and lifestyle habits.

References:

1. North American Menopause Society. (2020). Menopause 101: A primer for the perimenopausal. 
2. Rubinow, D. R., Schmidt, P. J., & Roca, C. A. (2002). Estrogen-serotonin interactions: Implications for affective regulation. Biological Psychiatry, 51(10), 864–880. 
3. Wei, M., Huang, R., Wang, J., Zhang, W., & Xu, T. (2021). Cortisol level, stress and depression in perimenopausal women. Gynecological Endocrin
4. Kudielka, B. M., & Wüst, S. (2010). Human models in acute and chronic stress: assessing determinants of individual hypothalamus–pituitary–adrenal axis activity and reactivity. Stress, 13(1), 1-14. doi: 10.3109/10253890902874913
5. Stalder, T., Kirschbaum, C., & Kudielka, B. M. (2016). Assessment of cortisol in saliva and serum. In The Oxford Handbook of Stress and Mental Health (pp. 75-89). Oxford University Press.
6. Hellhammer, D. H., Wüst, S., & Kudielka, B. M. (2009). Salivary cortisol as a biomarker in stress research. Psychoneuroendocrinology, 34(2), 163-171. doi: 10.1016/j.psyneuen.2008.10.026
7. Chrousos, G. P. (2009). Stress and disorders of the stress system. Nature Reviews Endocrinology, 5(7), 374-381. doi: 10.1038/nrendo.2009.106
8. Epel, E. S., McEwen, B., Seeman, T., Matthews, K., Castellazzo, G., Brownell, K. D., ... & Ickovics, J. R. (2000). Stress and body shape: stress-induced cortisol secretion is consistently greater among women with central fat. Psychosomatic Medicine, 62(5), 623-632. doi: 10.1097/00006842-200009000-00003
9. Dimsdale, J. E. (2008). Psychological stress and cardiovascular disease. Journal of the American College of Cardiology, 51(13), 1237-1246. doi: 10.1016/j.jacc.2007.12.024
10. Lattie, E. G., Asvat, Y., & Shivpuri, S. (2016). A review of mindfulness-based stress reduction for stress management in healthy individuals and populations. Complementary Therapies in Clinical Practice, 22, 37-41. doi: 10.1016/j.ctcp.2015.12.005