Adrenal Health and Perimenopause: A Guide to Cortisol, Stress, and What to Do

Why your adrenal glands matter more in perimenopause

Your adrenal glands sit just above your kidneys and produce several hormones your body depends on, including cortisol, DHEA, adrenaline, and small amounts of sex hormones. During perimenopause, when the ovaries begin producing less estrogen and progesterone, the adrenal glands become a secondary source of certain hormones, including a weak estrogen precursor called androstenedione and DHEA.

This increased demand on the adrenals happens at the same time that many women in midlife are also carrying heavy stress loads, sleeping poorly, and dealing with erratic hormonal fluctuations that themselves act as physiological stressors. The result is that the adrenal system is asked to do more while often running on less recovery.

Understanding how this works helps explain some of the most frustrating perimenopause experiences: the wired-but-tired feeling, the crashes after stressful periods, the difficulty recovering from exertion, and the way anxiety seems to have a life of its own even when your circumstances are not objectively worse than before.

Cortisol basics: what it does and when it becomes a problem

Cortisol is your primary stress hormone. It is also essential for blood sugar regulation, immune function, blood pressure management, and the wake-sleep cycle. A healthy cortisol pattern looks like high levels in the morning that help you wake up and feel alert, tapering off through the day to lower levels at night.

When stress is chronic, this pattern can become dysregulated. Cortisol may stay elevated through the evening, interfering with sleep. Or the pattern may flatten over time, leaving cortisol lower than optimal across the day, which contributes to fatigue, low motivation, and difficulty coping with even ordinary demands.

Estrogen and cortisol interact directly. Declining estrogen during perimenopause reduces the buffering effect on the stress response, making the cortisol system more reactive. This is one reason that anxiety and irritability often increase during perimenopause even for women who previously felt stress-resilient. The underlying physiology has changed.

Signs that your stress response may be dysregulated

Several patterns are common when the adrenal and cortisol system is under strain during perimenopause. None of these are diagnostic on their own, but clusters of them are worth paying attention to.

Feeling wired in the evening but exhausted in the morning is a classic sign of cortisol pattern disruption. Waking between 2 and 4 am, often feeling anxious or alert for no clear reason, can reflect a cortisol spike in the early morning hours. Feeling deeply fatigued but unable to sleep despite that fatigue is another common experience.

Crashing after periods of high demand, needing days to recover from events that would not have affected you as much previously, is a sign that recovery capacity has reduced. Increased sensitivity to stimulants like caffeine, heart palpitations during low-stress moments, and a sense of internal nervous system buzzing can also reflect an overloaded stress response.

It is worth noting that these symptoms overlap significantly with low thyroid function, iron deficiency, and other conditions. Testing is important before assuming the cause.

What the evidence says about supporting adrenal health

There is no single supplement or protocol that fixes a dysregulated stress response, but several well-supported approaches make a genuine difference.

Sleep is the highest-priority intervention. The adrenal glands and cortisol system reset and recalibrate during sleep. Protecting sleep quality, treating night sweats that disrupt it, and addressing sleep anxiety early matter more than any supplement.

Blood sugar stability has a direct effect on cortisol. Skipping meals, relying on caffeine and refined carbohydrates, and going long stretches without eating all trigger cortisol spikes. Eating regular meals that include protein, healthy fat, and fiber keeps blood sugar steadier and reduces unnecessary stress signaling.

Adaptogenic herbs have the most research among supplements for stress and cortisol. Ashwagandha (Withania somnifera) has been studied in multiple randomized controlled trials showing reductions in self-reported stress, cortisol levels, and anxiety in adults under chronic stress. Rhodiola rosea has evidence for fatigue and mental performance under stress. Both are generally well-tolerated but should be discussed with your provider if you take medications, particularly thyroid drugs or sedatives.

Vitamin C is concentrated in the adrenal glands and is used in cortisol production. Ensuring adequate intake through diet or supplementation is reasonable. Magnesium, B vitamins (particularly B5 and B6), and adequate dietary protein all support the adrenal hormone production pathway.

Movement: the dose-response relationship with stress

Exercise is one of the most effective tools for recalibrating the stress response, but the type and intensity matter during perimenopause, especially when the stress system is already strained.

Moderate aerobic exercise, walking, swimming, cycling at a comfortable pace, consistently lowers baseline cortisol over time and improves the brain's capacity to regulate emotional responses. It also improves sleep quality, which cascades into better cortisol rhythm.

High-intensity exercise is genuinely valuable for perimenopause, particularly for bone density and metabolic health. But for women experiencing significant adrenal stress symptoms, daily hard training can be counterproductive. Very intense exercise is itself a cortisol trigger. If you are in a period where you feel wired and depleted simultaneously, prioritizing moderate exercise and genuinely restful recovery days may serve you better than pushing harder.

Strength training several times per week is particularly useful because it builds lean muscle, which improves insulin sensitivity and helps buffer the effects of cortisol on body composition. The stress response tends to drive fat storage around the abdomen. Consistent resistance training counters this effect.

Reducing the sources of chronic stress load

Lifestyle interventions work, but they work better when combined with an honest look at the sources of chronic stress that are within your control to change.

For many women in midlife, the stress load is structural: primary caregiving for children and aging parents simultaneously, career demands that have not scaled back even as health demands have increased, and social obligations that feel non-negotiable. Not all of these can be changed quickly. But identifying where you have genuine flexibility, and protecting time for recovery rather than letting it be the first thing sacrificed, makes a physiological difference.

Social connection has a direct cortisol-lowering effect. Time spent with people who feel safe and restorative, not draining, is not a luxury. It is a biological input.

Mindfulness-based practices, including meditation, breathing exercises, and body-scan practices, have strong evidence for reducing cortisol and improving stress reactivity over time. Even 10 minutes daily of deliberate slow breathing, which activates the vagus nerve and the parasympathetic nervous system, produces measurable changes over weeks.

What to ask your doctor