Your Adrenal Glands in Perimenopause: Why They Matter More Than You Might Think

What Your Adrenal Glands Actually Do

When most people think about adrenal glands, they think about the stress response, specifically cortisol and adrenaline. And while those are certainly major adrenal functions, the adrenals do considerably more than manage acute stress. They produce a broad range of hormones including DHEA, DHEA-S, androstenedione, and small amounts of sex hormones including testosterone and estrone. During your reproductive years, these adrenal contributions are relatively minor compared to what your ovaries produce. In perimenopause and beyond, they become significantly more important.

DHEA (dehydroepiandrosterone) and its sulfated form DHEA-S are produced almost exclusively by the adrenal glands and serve as precursor hormones from which other sex hormones are made in peripheral tissues. Fat cells, muscle, skin, bone, and the brain all have the enzymes needed to convert DHEA into estrogens and androgens locally. This process of local hormone production in tissues, called intracrinology, means that even after your ovaries stop producing estradiol, your body continues to make and use sex hormones from adrenal precursors, at least to some degree.

DHEA production peaks in your mid-20s and declines steadily with age, by about 1 to 2 percent per year. By the time most women are in their late 40s or early 50s, DHEA levels have already dropped substantially from their peak. This age-related decline, combined with the loss of ovarian estrogen in perimenopause, is why adrenal function becomes a more meaningful factor in how you feel during this transition. Supporting your adrenal glands isn't about chasing a cure. It's about making sure this secondary hormone production system is functioning as well as it can.

The Adrenal Fatigue Debate: What's Real and What Isn't

If you've spent any time in integrative health circles, you've almost certainly encountered the concept of adrenal fatigue: the idea that chronic stress can exhaust the adrenal glands, leaving them unable to produce adequate cortisol and causing symptoms like fatigue, brain fog, low mood, and difficulty getting through the day. This concept is popular in functional medicine and wellness communities but is not recognized as a formal diagnosis by mainstream endocrinology.

The mainstream medical position is that adrenal exhaustion leading to insufficient cortisol production simply doesn't happen in the absence of specific adrenal disease (like Addison's disease) or exogenous corticosteroid use. True adrenal insufficiency is a serious medical condition with measurable cortisol deficiency, distinct from the vague symptom constellation attributed to adrenal fatigue in wellness contexts. Endocrinologists are concerned that the adrenal fatigue concept leads to unnecessary testing, unnecessary supplementation with DHEA and other hormones, and missed diagnoses of actual conditions.

However, something called HPA axis dysregulation is a real phenomenon and is recognized in mainstream medicine, even if the term adrenal fatigue is not. The hypothalamic-pituitary-adrenal (HPA) axis regulates cortisol production in response to stress, and this regulatory system can become dysregulated by chronic physical or psychological stress. Dysregulated HPA axis function doesn't typically mean inadequate cortisol. It means the normal diurnal pattern of cortisol, with a morning peak and gradual decline through the day, becomes blunted or disrupted. This can affect energy, sleep, immune function, and inflammation regulation in ways that feel very much like what people describe as adrenal fatigue.

HPA Axis Dysregulation: Why Perimenopause Is a Vulnerable Period

Perimenopause is a period of heightened vulnerability for HPA axis dysregulation for several reasons. First, estrogen and progesterone both directly modulate HPA axis activity. As these hormones fluctuate and decline, the HPA axis regulation that depended on them is disrupted. Hot flashes are themselves a stressor that triggers cortisol release, and if they're happening multiple times a night, your cortisol rhythm can be significantly disrupted by sleep fragmentation alone.

Second, the life circumstances of women in perimenopause often involve elevated demands: career responsibilities, caregiving for both children and aging parents, relationship transitions, and the psychological stress of navigating a major life transition while experiencing confusing physical symptoms. Chronic psychological stress is one of the primary drivers of HPA axis dysregulation, and perimenopause frequently coincides with periods of unusually high life demands.

Third, the body responds to the loss of ovarian hormones by leaning more heavily on adrenal hormone production. This increased demand on the adrenals, combined with the other stressors described, can push HPA function toward the dysregulated end of the spectrum. Women who already had poorly regulated stress responses, whether from prior burnout, chronic illness, or other factors, may find that perimenopause amplifies these issues significantly.

Testing Cortisol: What the Options Are and What They Tell You

If you want to assess your HPA axis function, several testing options are available, each capturing different aspects of cortisol production. Standard serum cortisol testing, typically done early in the morning, captures a single point in time and can confirm gross abnormalities like Addison's disease or Cushing's syndrome, but it misses the more subtle diurnal rhythm disruptions that characterize HPA dysregulation.

Saliva cortisol testing collected at multiple points throughout the day (typically upon waking, morning, afternoon, and evening) gives you a picture of the cortisol curve over the course of a day. This is how functional medicine practitioners most commonly assess HPA axis function. The four-point saliva cortisol test can reveal whether your morning cortisol is appropriately elevated (the cortisol awakening response), whether it declines appropriately through the day, and whether evening cortisol is appropriately low. Abnormalities in this curve, such as a blunted morning peak or elevated evening cortisol, are associated with fatigue, sleep problems, and impaired stress response.

The DUTCH (dried urine test for comprehensive hormones) measures cortisol and cortisol metabolites in urine collected at multiple points, and provides additional information about how the body is metabolizing cortisol. This can be useful for understanding whether total cortisol production is normal even when the free cortisol curve looks abnormal. None of these tests are used in mainstream endocrinology for routine assessment, but they're used in integrative and functional medicine contexts where practitioners are looking at HPA function as part of a broader picture.

Adaptogen Evidence: What Actually Has Research Support

Adaptogens are a class of botanicals traditionally used in Ayurvedic and traditional Chinese medicine to support the body's resilience to stress. In recent years, several adaptogens have been studied specifically for their effects on HPA axis function and cortisol regulation. The quality of evidence varies considerably, but some adaptogenic herbs have meaningful research supporting their use.

Ashwagandha (Withania somnifera) is probably the most studied adaptogen for stress and HPA axis support. Multiple randomized controlled trials have found that ashwagandha supplementation reduces serum cortisol levels, improves perceived stress and anxiety, and improves sleep quality. A 2019 study found significant reductions in cortisol levels and anxiety scores in adults taking 240mg of standardized ashwagandha extract daily for 60 days. For perimenopausal women with elevated stress, poor sleep, and anxiety, ashwagandha is one of the more evidence-backed supplement options to consider.

Rhodiola rosea has research supporting improved fatigue and stress resilience, with several trials showing benefits for burnout-related fatigue and cognitive performance under stress. Eleuthero (Siberian ginseng) has a long history of use and some evidence for stress adaptation and fatigue, though the research base is less rigorous. Phosphatidylserine has good evidence for reducing cortisol responses to acute psychological and physical stress. These are not replacements for the lifestyle and medical interventions discussed elsewhere, but as supporting elements of a broader approach, several adaptogens have enough evidence to be worth considering.

Lifestyle Approaches That Support HPA Function

The most effective support for HPA axis health comes from lifestyle interventions, many of which overlap with general perimenopause wellness recommendations. Sleep is foundational: the cortisol awakening response and the diurnal cortisol curve are heavily dependent on the sleep-wake cycle, and chronic sleep disruption, which is extremely common in perimenopause, is a major driver of HPA dysregulation. Treating night sweats and insomnia through whatever means are effective for you directly supports healthier HPA function.

Nutrition timing and composition also matter. Skipping meals or going long periods without eating can trigger cortisol release as the body mobilizes energy stores. Eating adequate protein throughout the day (a general target of at least 1.2g per kilogram of body weight is reasonable for active perimenopausal women) helps stabilize blood sugar and reduce the metabolic stressors that can tax HPA function. Excessive caffeine, particularly later in the day, keeps cortisol elevated and can worsen the diurnal rhythm disruption that comes with HPA dysregulation.

Mind-body practices, including meditation, yoga, breathwork, and mindfulness, have measurable effects on HPA axis function. Regular practice lowers baseline cortisol, improves the cortisol awakening response, and reduces the cortisol spike associated with acute stressors. Even 10 to 15 minutes of daily practice appears to produce meaningful changes in HPA regulation over weeks to months. This isn't about eliminating stress from your life. It's about building the physiological capacity to recover from stress more efficiently.

DHEA Supplementation: When It Makes Sense

DHEA is available over the counter in the United States and is one of the more commonly self-prescribed supplements in the perimenopause and menopause space. Given that DHEA-S declines with age and serves as a precursor for sex hormone production in peripheral tissues, the idea that supplementing DHEA might support hormone levels has intuitive appeal.

The evidence for systemic oral DHEA supplementation in perimenopause is modest and mixed. Some studies show improvements in mood, wellbeing, and sexual function in women with low DHEA-S levels. Others show minimal benefit in women with normal DHEA-S levels for their age. DHEA can be converted to testosterone in the body, which may explain some of the positive effects on libido and energy that women report. It can also convert to estrogen, which raises questions about its use in women with estrogen-sensitive conditions.

Intravaginal DHEA (sold as Prasterone, brand name Intrarosa) is FDA-approved specifically for painful intercourse associated with menopause, representing one of the best-supported uses of DHEA in this population. For systemic use, testing your DHEA-S level before supplementing is advisable. If your level is genuinely low for your age, a low dose of 10 to 25mg daily is often recommended rather than the higher doses (50 to 100mg) commonly available in stores. Higher doses increase the risk of androgenic side effects like acne and hair changes. Working with a provider knowledgeable in this area is important if you're considering DHEA supplementation.

Medical Disclaimer

This article is written for general informational purposes only and does not constitute medical advice. Adrenal and HPA axis assessment and any supplementation or treatment decisions should always be made in partnership with a qualified healthcare provider who knows your full medical history. The information here is not a substitute for a clinical evaluation. If you have concerns about fatigue, stress response, or perimenopause symptoms, please consult a licensed medical professional.