Stress and menopause: understanding cortisol and everyday techniques that help

Cortisol is a hormone produced by the adrenal glands that helps the body respond to stressful situations. However, it also plays a vital role in maintaining blood pressure and regulating metabolism, blood glucose and inflammation.

During the menopausal transition, fluctuations and declining oestrogen levels can affect cortisol release. The most direct relationship during this period is linked to the perception of stress and the mechanisms it triggers, particularly at a stage of life when physical and psychological changes can have a significant emotional impact.

Symptoms such as fatigue, insomnia, anxiety, brain fog or increased abdominal fat are not enough to diagnose high cortisol levels. These symptoms are very common and can have many different causes, including the menopausal transition itself.

Pathological and prolonged excess cortisol can produce a more characteristic set of signs and symptoms:

• Progressive weight gain around the abdomen and trunk, with relatively thin arms and legs.
• A more rounded face.
• Muscle weakness, particularly in the thighs and shoulders.
• High blood pressure or diabetes that is difficult to control.
• Easy bruising and thin skin.
• Wide, purple stretch marks.
• Osteoporosis or fractures.
• Menstrual changes, increased body hair or significant changes in mood.

Stress can increase the perceived intensity and impact of other symptoms. It activates the sympathetic nervous system, increases alertness and can make it more difficult to sleep.

Acute stress is a normal response. When faced with a threat, illness or physical exercise, cortisol levels temporarily rise to mobilise glucose, maintain blood pressure and help the body adapt. Afterwards, cortisol should return to its usual pattern.

Chronic hypercortisolism refers to excessive and sustained exposure to cortisol. It can be caused by corticosteroid medication or, less commonly, by disorders affecting the pituitary or adrenal glands. When sufficiently severe, it can lead to diabetes, high blood pressure, muscle weakness, osteoporosis, infections and cognitive or emotional changes.

Chronic psychological stress does not always result in consistently elevated cortisol levels. It can also lead to:

• A flattened daily cortisol rhythm.
• Inappropriately elevated cortisol levels at night.
• An altered cortisol awakening response.
• An exaggerated or, in some cases, reduced response to a stressor.

For this reason, “feeling stressed” and “having hypercortisolism” are not equivalent diagnoses.

It is possible to collect a saliva sample at home, but the test needs to be appropriately indicated and correctly interpreted. When investigating a possible excess of cortisol, one option is to collect a saliva sample between 11:00 pm and midnight, when cortisol levels would normally be very low.

Commercial “stress profile” testing kits have several limitations:

• A single sample can be affected by the time of day, sleep, exercise or illness.
• Eating, drinking, smoking or brushing your teeth can affect a saliva sample.
• Contraceptives and oral oestrogens can affect certain measurements.
• An out-of-range result alone is not sufficient to diagnose Cushing's syndrome.
• The reference ranges and methods used by commercial laboratories are not always validated for diagnostic purposes.

If there is clinical suspicion, it is preferable for a healthcare professional to request the appropriate test and confirm any abnormal result using a second method.

Regular exercise can improve sleep, anxiety, insulin sensitivity and the ability to cope with stress. However, it does not necessarily reduce baseline cortisol levels in all women.

An intense exercise session — particularly high-volume strength training, training with short rest periods or sets performed to muscular failure — can temporarily increase cortisol levels. This increase is a normal physiological response and is not automatically a sign of harm.

In the long term, combining strength and aerobic exercise can improve overall stress regulation, even when measured cortisol levels do not change. Strength training is also particularly important during menopause because it helps preserve muscle mass, strength, bone health and metabolic function.

A meta-analysis of 16 trials involving 922 participants found that strength training modestly reduced anxiety (Gordon et al., 2017). A reasonable exercise routine may include:

• Strength training two or three times a week.
• Moderate aerobic activity spread throughout the week.
• Gradual progression and adequate recovery.
• Avoiding consistently training to exhaustion.
• Adjusting training load when experiencing severe insomnia, illness or persistent fatigue.

In summary, exercise should not be viewed as a way to “eliminate cortisol”, but rather as a strategy to improve the body's ability to activate and appropriately switch off the stress response.