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Breakthrough: Cortisol Plays a Critical Role in Menopause

Updated: Nov 14, 2022

Medically reviewed by Ioana Bina, MD, PhD

Menopause is one of the biggest biological changes women go through.

After all, it doesn’t only disrupt and end menstrual cycles. For some women, it can upend sleep patterns, metabolic processes, cardiovascular health and even mental wellbeing. Not to mention the random hot flashes. Some of these symptoms can last upward of a decade.

That can be stressful. Seemingly sudden and arbitrary changes to your body always are. But what if we told you these changes didn’t have to feel so sudden? What if women could feel better prepared, less anxious and more in control when menopause hits?

That’s one of the key reasons we started digging into this area of endocrinology. At Pardigm, we’re interested in helping people by exploring the science behind cortisol, the main stress hormone. But stress is only a fraction of the cortisol equation.

Cortisol also plays a role in, you guessed it, menopause. In fact, the more we investigated and consulted with our panel of experts … the more we realized just how important (and overlooked) that role is.

Recently, some Stanford OB-GYN professors introduced us to Professor Sarah Berga, M.D. who made several scientific breakthroughs. Dr. Berga whose research focuses on reproductive endocrinology, specifically stress’s role in reproductive compromise sits on the Mayo Clinic Proceedings and previously on The Journal of Clinical Endocrinology & Metabolism editorial board.

Dr. Berga and the well-known Seattle Midlife Women’s Health Study suggest that cortisol is an underappreciated factor in menopause symptoms, not only estrogen or progesterone imbalances as many scientists previously thought.

But there’s hope. If women are able to sustain an optimal cortisol level, it could dictate just how well the transitional period goes for them…

Cortisol’s Role in Menopause

Menopause is a natural stage in life, despite it only occurring in humans and a few marine mammals. As women enter their 40s, their ovaries tend to produce fluctuating levels of estrogen. This production decreases until they no longer menstruate. At some, point their ovaries “retire” they cease to produce sex hormones and the adrenal glands take over. Once 12 months have passed since their last period, they’ve officially reached menopause.

That’s the simple version of events. But biology is never simple.

To show you what we mean, let’s start with the four main hormones to watch during menopause:

Estrogen: When we think about menopause, we typically first think about estrogen – we’re referring mostly to estradiol (E2) – the sex hormone that regulates the menstrual cycle. When estrogen levels drop, usually around or after the age of 45, this signals perimenopause (the start of the transition to menopause). However, estrogen isn’t simply dwindling during this time. It’s rising and falling like a rollercoaster, right up until it plummets.

This spawns many of the menopausal symptoms women experience, but it isn’t a completely straightforward causal relationship.

For one, low and high estrogen levels are also seen as a stressor for the body, which can affect cortisol levels. That’s why it’s critical to balance cortisol levels throughout our lives, especially during menopause.

Interestingly, as a result of the steep increase in life expectancy, many women will spend the second half of their lives with an estrogen deficiency. Estrogen deficiencies have been linked to degenerative diseases of the cardiovascular, skeletal and central nervous systems. Low estrogen can also enhance metabolic dysfunction, which can lead to obesity, metabolic syndrome, type 2 diabetes, and even cancers (such as breast, colon, and liver cancer).

But here’s something else to consider: As estrogen decreases, it also throws off the balance with progesterone…

Progesterone: Before menopause, women were typically adept at buffering stress because progesterone often called the “feel good” hormone and the pregnancy hormone and dehydroepiandrosterone (DHEA) were produced along with cortisol, balancing out cortisol’s effects.

However, once women enter perimenopause, their progesterone levels often decrease, and they have less of a stress buffer.

In one recent study, researchers found that those with higher levels of progesterone during perimenopause experienced significantly higher life satisfaction, lower perceived stress, and lower depressive symptoms than women with lower levels. However, progesterone may also cause somnolence and depression in some women and raises glucose levels which could have negative effects on insulin resistance.

Meanwhile, as progesterone declines, the stress hormone might be on the upswing…

Cortisol: Here’s the thing to understand about cortisol … it’s not only the main stress hormone. It also regulates your sleep-wake cycle, blood sugar levels, energy metabolism, blood pressure and more. When at optimal levels, it’s quietly working behind the scenes along with a score of other hormones, ensuring you’re operating at top form.

Of course, beyond those everyday jobs, cortisol is also key to your stress response. When you’re stressed be it physically or mentally your adrenal glands start pushing out more cortisol to help you handle the threat. This can shut down functions considered “non-essential”all to help you conserve energy.

In short bursts, that’s great for your survival. However, long-term cortisol imbalances can continue to suppress non-essential functions, such as your digestion and reproductive system, and cause various health problems.

That’s why it’s so important to measure and address your cortisol in general. But as Dr. Berga tells us, women entering menopause particularly want to validate their cortisol levels.

For one, cortisol levels rise with age. But as we also addressed, low estrogen can affect cortisol levels. So it’s no wonder that menopause is a stressful period and that menopause symptoms echo many of those seen in cortisol imbalances, such as:

  • Weight gain

  • Cravings for unhealthy foods

  • Insomnia and other sleep issues

  • Low energy

  • Low sex drive

  • More aches and pains

  • Mood changes and depression

  • Skin and hair issues

Testosterone: Finally, both men and women produce testosterone in different parts of the body. But this crucial hormone decreases over time, with significant effects on each gender. In fact, many symptoms tied to this can echo premenopausal symptoms in women. For example, sex drive and muscle strength may drop, while depressive symptoms, fatigue and sleep issues rise. Another study found that depressive symptoms were linked to a higher testosterone-to-estrogen ratio during menopause .

Our bodies are doing their best work adapting through menopause. However, our adrenal glands aren’t as efficient at producing progesterone and other hormones when they’re constantly pumping out cortisol. Our bodies will always choose survival over fertility. And so, we deal with the knock-on effects.

For example, researchers studied 85 healthy women who were in early menopause (six months to five years postmenopause). The women’s 24-hour urinary cortisol levels and Greene Climacteric Scale scores (a brief measure of menopause symptoms) were evaluated, along with lipid levels. At the end, researchers determined a relationship between all hormones. In other words, menopausal symtoms were associated with increased cortisol. And as the study cites: “Increased cortisol is associated with known risk factors for cardiovascular disease, such as insulin resistance and decreased (beneficial) HDL-cholesterol level.”

In fact, excess cortisol can get stored as cortisone in the fat cells around your organs through an enzyme called 11betaHSD1. Once reactivated and released, the cortisol stimulates overeating, more visceral fat deposits and the onset of diabetes; and it can provoke feelings of depression. The low energy levels of menopause can also be exacerbated here. Elevated cortisol levels can lower thyroid function, further depriving energy.

Another study found that women with greater hot flash frequency had a different cortisol pattern compared to women with few hot flashes. Those with the higher frequency had lower mean cortisol values upon waking. (They even trended toward higher bedtime cortisol and a diminished diurnal variation, although neither of these were statistically significant.) These types of imbalances can affect everything from sleep quality to energy levels.

The good news is that you can reduce menopause symptoms such as hot flashes, sleep disturbances and mood changes by balancing your cortisol levels.

In one study, 69 postmenopausal women were treated for their menopausal symptoms with either estrogen progestin therapy, phytoestrogens or acupuncture (once a week). Researchers evaluated their cortisol levels and reported that “greater reduction in menopausal symptoms is associated with a larger decrease in cortisol levels. Possible implication of this finding on the long-term consequences for women's health needs to be explored.”

While the relationship between cortisol, estrogen, progesterone, testosterone and other hormones in both women and men is complicated, one thing is clear: When one hormone falls out of balance, others fall too. It’s an intricate domino effect, and it means women entering menopause aren’t just feeling psychologically stressed. They’re physically stressed too.

There’s a Reason for Your Stress

Before menopause, women’s bodies are more likely to have optimal levels of progesterone and estrogen, which provide excellent stress buffers. But as bodies age, and hormonal levels start to go haywire during perimenopause, women have less cushion against stress and high cortisol.

For those entering menopause, that can feel overwhelming. After all, premenopausal and menopausal women are often not told about the importance of hormonal changes and the best ways to mitigate them. Instead they are medicalized and prescribed antidepressants and anxiolytics, which Dr. Ioana Bina tells us will at best provide minimal benefits over a placebo. Ultimately, they tend to have serious side effects and do not address the root of the problem.

5 Ways to Get Ahead of It

But there’s hope here. The first step to taking back control is understanding what’s happening in your body and trying to get ahead of developing issues.

Here are five ways to do that:

  1. Measure your cortisol pattern, which you can soon do easily from home. This matters. Professors Sara Berga, Alia Crum and other researchers show that it can be beneficial to balance your cortisol rhythm. And we’re here to support you on this journey.

  2. Change your mindset by making stress work for you in three steps.

  3. Stay active in the right way. As Dr. Ioana Bina tells us, it’s important to prevent muscle and bone loss after menopause. Higher muscle mass has been linked to brain health, a higher metabolic rate and protection from frailty and falls. Menopause can decrease bone-mass density, muscle mass, and increase fat, which can add more stress to your system. Lift weights and gain muscle, while ensuring you’re not overdoing it. Too much exercise (too prolonged, too frequent or too strenuous), can cause a deleterious increase in cortisol - that is counterproductive leading to muscle loss and resistance to weight loss and body composition changes.

  4. Adjust your diet and incorporate more protein into your meals because menopause makes it more difficult for your muscle to use protein. You can shoot for 25 to 30 grams (ideally) of good quality protein shortly after working out and with each meal. Remember to also incorporate nutritious whole foods, mainly from plant-based sources, healthy fats, as well as herbs and spices, rich in polyphenols, fiber and fermented foods as tolerated.

  5. Finally, investigate bioidentical hormone replacement therapy, which, if implemented, should be done as soon as possible after reaching menopause. The risk-benefit ratio becomes less favorable after 10 years. “Bioidentical" means that the hormones used are chemically identical to the ones your body produces. As mentioned above, many women are prescribed antidepressants and anxiolytics instead of being told about the importance of hormonal changes and the best ways to mitigate them.

These steps can help you get ahead if any hormonal imbalances are affecting your body and, ultimately, your wellbeing.

To read more of our research on reproductive health, you can find our review of cortisol and fertility issues here.

Before you go, we have one more question for you: How can we get better? Here at, our goal is to gather the best information to help you understand the science of stress. If you think we missed anything in our research, please let us know here.


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