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Reference Guide
Cortisol Waking
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Cortisol Waking

Waking cortisol is the level of cortisol present in the bloodstream upon waking.  Cortisol, a glucocorticoid hormone produced by the adrenal cortex, plays a crucial role in the body's stress response and overall metabolism. 

Synthesized from cholesterol, cortisol production is regulated by the hypothalamic-pituitary-adrenal (HPA) axis. 

The hypothalamus releases corticotropin-releasing hormone (CRH), which stimulates the anterior pituitary to secrete adrenocorticotropic hormone (ACTH). ACTH then prompts the adrenal cortex to produce cortisol. 

This hormone follows a diurnal rhythm, peaking in the early Waking to help wakefulness and declining throughout the day to promote sleep.  Cortisol influences various bodily functions, including glucose metabolism, immune response, and blood pressure regulation. 

Testing Waking cortisol levels can provide insights into the function of the HPA axis, aiding in diagnosing conditions like Cushing's syndrome and Addison's disease, as well as assessing the impact of chronic stress and other health issues.

Definition and Function of Cortisol

What is Cortisol?  [21.]

Classified as a glucocorticoid hormone, cortisol is a crucial component of the body's stress response system.

It is synthesized from cholesterol through a series of enzymatic reactions in the zona fasciculata of the adrenal cortex.  Cortisol is produced in the steroidogenesis pathway, which encompasses the biosynthesis of steroid hormones from cholesterol. 

Cortisol Production and Regulation  [21.] 

Cortisol production and regulation are tightly controlled processes orchestrated by the hypothalamic-pituitary-adrenal (HPA) axis.  

The hypothalamus releases corticotropin-releasing hormone (CRH), which stimulates the anterior pituitary gland to secrete adrenocorticotropic hormone (ACTH). ACTH then prompts the zona fasciculata of the adrenal cortex to synthesize and release cortisol into the bloodstream. 

Once the circulating cortisol level reaches a certain threshold it negatively feeds back to inhibit the release of CRH and ACTH, effectively regulating its own production. This feedback loop ensures that cortisol levels remain within a narrow physiological range, adapting dynamically to stressors and maintaining homeostasis throughout the body.

Cortisol has free and bound fractions: cortisol is bound to a carrier protein (often cortisol-binding globulin or albumin).  The free fraction is the biologically active pool of cortisol; the bound pool of cortisol becomes biologically active when it is released from its carrier protein.  Only 3-5% of circulating cortisol is available in its free, unbound form.  [3.]

Function of Cortisol: What Does Cortisol Do?

As a glucocorticoid hormone, cortisol exerts its effects by binding to glucocorticoid receptors in target tissues.  Because glucocorticoid receptors are present in almost every tissue of the body, cortisol has far-reaching effects in influencing gene expression and regulating metabolism, immune function, inflammation, and stress response.

Some specific functions of cortisol include:

Regulates metabolism: cortisol influences glucose metabolism by promoting gluconeogenesis, the production of glucose from non-carbohydrate sources, and inhibiting glucose uptake in peripheral tissues.  [21.]

Modulates immune response: cortisol has anti-inflammatory properties and suppresses immune function by inhibiting the release of pro-inflammatory cytokines and reducing the activity of immune cells including lymphocytes and macrophages.

Supports stress response: cortisol is often referred to as the "stress hormone" because it helps the body cope with physical and psychological stressors by mobilizing energy reserves, increasing alertness, and suppressing non-essential functions during times of perceived danger.  It does this through complex interactions between the brain and autonomic nervous system.  [21.]

Regulates blood pressure: cortisol contributes to blood pressure regulation by enhancing vasoconstriction, the narrowing of blood vessels, and increasing the sensitivity of blood vessels to other vasoconstrictors like adrenaline.  [24.]

Influences fluid and electrolyte balance: cortisol regulates fluid balance by enhancing the reabsorption of sodium and water in the kidneys while promoting the excretion of potassium, helping to maintain electrolyte balance.  [1.]

Affects mood and behavior: cortisol can influence mood, cognition, and behavior by interacting with neurotransmitter systems in the brain, particularly those involved in stress response and emotional regulation.  [7.]

Supports fetal development: cortisol plays a crucial role in fetal lung maturation and surfactant production during pregnancy, aiding in the development of the respiratory system.

Regulates sleep-wake cycle: cortisol follows a diurnal rhythm, with levels typically peaking in the early Waking hours to help facilitate wakefulness and declining throughout the day to promote relaxation and sleep at night.

Maintains bone health: cortisol modulates bone turnover by inhibiting bone formation and promoting bone resorption, which can lead to bone loss and increase the risk of osteoporosis when chronically elevated.  [2.]

The Cortisol Awakening Response: How Long After Waking Does Cortisol Peak?

In healthy individuals, cortisol is expected to rise in the morning by as much as 50%, peak approximately 30 minutes after waking, and fall back to morning waking levels within 60 minutes of waking.  

This is called the Cortisol Awakening Response, or CAR, and it provides valuable insight into the functioning of the HPA axis.  [27.]

The AM30 cortisol measurement is an essential measurement in assessing the CAR.  

The CAR is clinically relevant because it reflects HPA axis function, which is associated with various physiological and psychological factors.  

Research suggests that a robust CAR is indicative of healthy stress regulation and adaptation, while blunted or exaggerated CARs are linked to conditions such as chronic stress, PTSD, depression, chronic fatigue, and burnout.  [27.]

Assessing CAR through laboratory testing can aid in identifying dysregulations in the hypothalamic-pituitary-adrenal (HPA) axis, which plays a central role in the body's stress response system. 

Why Test Waking Cortisol Levels?  [10., 20., 23., 26.] 

Testing waking cortisol levels is important in evaluating the function of the hypothalamic-pituitary-adrenal (HPA) axis, which plays a crucial role in regulating the body's stress response and maintaining homeostasis. 

Waking cortisol levels are particularly informative because they reflect the natural diurnal rhythm of cortisol secretion, which typically peaks in the early morning hours.

Measuring waking cortisol levels can help diagnose various conditions related to cortisol dysregulation including Cushing's syndrome (excess cortisol production) or Addison's disease (cortisol deficiency).  Waking cortisol levels can also be used to monitor the effectiveness of treatment for these conditions and to assess the recovery of the HPA axis after treatment.

Abnormal waking cortisol levels can also be indicative of pituitary or hypothalamic disorders, which can disrupt the normal regulation of cortisol secretion.

Furthermore, waking cortisol levels can provide insights into other conditions that may affect the HPA axis such as chronic stress, depression, and certain types of tumors.  

Increased stress, poor sleep quality, or underlying inflammatory conditions can all disrupt normal cortisol cycles.  When the body experiences chronic stress or insufficient sleep, it can disrupt the normal diurnal rhythm of cortisol secretion, leading to altered waking cortisol levels. 

Additionally, inflammatory processes can stimulate the hypothalamic-pituitary-adrenal (HPA) axis, resulting in increased cortisol production.  Persistently high waking cortisol levels can have far-reaching impacts on overall health and well-being and cause weight gain, mood disturbances, and brain fog, among other symptoms.

Cortisol levels are best interpreted within the context of the diurnal cortisol rhythm; assessing the CAR (cortisol awakening response) may provide additional information. 

Symptoms of High Waking Cortisol Levels

Weight Gain, Especially Around the Abdomen  [8.]

One of the most common symptoms associated with high Waking cortisol levels is weight gain, particularly in the abdominal region.  Cortisol plays a role in regulating metabolism and fat distribution, and chronically elevated cortisol leads to an increase in visceral fat accumulation around the midsection.

Elevated cortisol levels are also associated with increased appetite and cravings for high-calorie foods. 

Fatigue and Low Energy  [9.]

Persistently high cortisol levels can disrupt the body's natural energy cycles, leading to feelings of fatigue and low energy throughout the day. This can make it challenging to perform daily activities and maintain productivity, further exacerbating stress levels and perpetuating the cycle of cortisol dysregulation.

Difficulty Concentrating or "Brain Fog"  [15.]

High cortisol levels can interfere with cognitive function, leading to difficulties in concentration, memory, and decision-making. This "brain fog" can be particularly problematic in work or academic settings, where mental clarity and focus are essential.

Headaches  [25.]

Elevated cortisol levels have been linked to an increased frequency and severity of headaches, including migraines. The exact mechanisms behind this association are not fully understood, but it is believed that cortisol may play a role in sensitizing pain pathways and triggering inflammatory responses.

Sleep Disturbances  [8.] 

Cortisol levels are closely tied to the body's sleep-wake cycle, and imbalances can contribute to sleep disturbances such as insomnia, difficulty falling asleep, or frequent awakenings during the night. Poor sleep quality, in turn, can further exacerbate cortisol dysregulation, creating a vicious cycle.

Irritability and Mood Swings  [7.]

High cortisol levels can impact mood and emotional regulation, leading to increased irritability, anxiety, and mood swings. 

Depression diagnoses have been correlated with increased cortisol levels.  People with anxiety also demonstrate a blunted stress response.  This can strain personal and professional relationships, as well as contribute to feelings of stress and overwhelm.

Testing Waking Cortisol Levels: Testing Methods

Blood, urine, and saliva testing are all common methods of cortisol assessment in the laboratory.  Each offers distinct clinical advantages, as listed below:

Blood Testing for Cortisol

Blood testing for cortisol involves drawing a blood sample from a vein, usually in the arm. This method measures the total cortisol concentration in the bloodstream, providing a snapshot of cortisol levels at the time of the test.


  • Widespread availability in medical facilities
  • Accurate measurement of total cortisol levels
  • Considered the gold standard of cortisol measurement


  • Requires venipuncture, which can be uncomfortable
  • Cortisol levels may fluctuate throughout the day, necessitating multiple blood draws, generally at least 2 within a 24 hour period (often at 8 am and 4 pm)
  • Does not provide accurate reflection of free, or bioavailable, cortisol levels  [3.]

Urine Testing for Cortisol

Urine testing for cortisol involves collecting a urine sample over a specified period, usually 24 hours, to measure the total cortisol excretion. This method provides an integrated measure of cortisol production over time and is less invasive than blood testing. 

Urine testing can show cortisol, cortisone, and metabolized cortisol levels.  


  • Non-invasive method
  • Samples can be collected at home
  • Demonstrates HPA axis function over 24 hours and cortisol metabolism 


  • Variations in urine volume and dilution can affect cortisol concentrations
  • Potential for incomplete sample collection, leading to inaccurate results

Saliva Testing for Cortisol

Saliva testing for cortisol involves collecting saliva samples at specific times throughout the day, typically upon waking, before lunch, before dinner, and before bedtime. This method measures free cortisol levels, which represent the biologically active form of cortisol available to tissues.


  • Non-invasive and painless sample collection
  • Saliva testing provides the ability to assess diurnal cortisol rhythms
  • Saliva testing is comparable to blood levels of free cortisol  [11.]


  • Potential variability in saliva collection technique
  • Oral health may have an effect on cortisol measurements

Understanding Cortisol Levels

Optimal Range for Cortisol Levels

Cortisol levels vary throughout the day, typically peaking in the Waking and decreasing gradually throughout the day. 24 hour salivary and urine tests will capture the diurnal rhythm, while multiple blood tests are required to assess the same information.  

It is essential to understand that lab values may vary. In blood, urine, and saliva, normal cortisol levels also vary throughout the day.  In blood, typical AM values range from : 6.2−19.4 μg/dL; PM: 2.3−11.9 μg/dL.  

In urine, they range from 10 to 50 ng/mg upon waking, and rise to 30-130 ng/mg in the Waking.  Urine cortisol measurements later in the day are expected to decline to 7-30 ng/mg in the afternoon, and down to 0-14 ng/mg at night.

Salivary cortisol levels are usually around 3.7 to 9.5 ng/mL upon waking and decrease throughout the day, to a low of about 0.4-1.0 ng/ml at night.

How to Lower High Cortisol Levels

Maintaining healthy waking cortisol levels is crucial for overall well-being and optimal health.  Fortunately, there are several lifestyle modifications and supplementation strategies that can help regulate cortisol and promote a balanced stress response.

Strategies to Lower Cortisol

  • Practice mindfulness-based stress reduction techniques, including meditation, deep breathing exercises, and yoga.  [22.]
  • Engage in regular physical activity and ensure adequate sleep each night to support cortisol regulation.  [4.]
  • Maintain a balanced diet rich in whole foods, while limiting caffeine, alcohol, and sugar intake to stabilize cortisol levels.
  • Foster a supportive social network and seek professional counseling or therapy to address underlying stressors effectively.
  • Consume a balanced diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats to provide essential nutrients for adrenal health and cortisol regulation.
  • Incorporate foods high in magnesium, such as leafy greens, nuts, seeds, and legumes, which may help reduce cortisol levels and promote relaxation.
  • Avoid excessive caffeine, refined sugars, and processed foods, as they can spike cortisol levels and contribute to chronic stress.  [5., 6., 13.] 

Supplements for Lowering Cortisol:

  • Herbal adaptogens: incorporate adaptogenic herbs like ashwagandha and holy basil into your routine to regulate cortisol levels and enhance stress resilience.  [12., 17.] 
  • Explore supplements such as phosphatidylserine to support adrenal health, reduce inflammation and maintain cortisol balance.  [19.]
  • Vitamin C: Supports adrenal gland function and cortisol production.  [16.]
  • B Vitamins (B5, B6, B12): Essential for adrenal hormone synthesis and energy metabolism.
  • Magnesium: Helps regulate cortisol levels and supports adrenal gland function.  [18.]
  • Zinc: Supports immune function and aids in adrenal hormone production.
  • Omega-3 fatty acids: Have anti-inflammatory properties and support adrenal health.  [14.]

Prior to initiating any new supplements it's crucial to consult with a healthcare provider, particularly if you have preexisting health conditions or are currently on medications, to guarantee safety and effectiveness.

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Cortisol Waking
Cortisol Waking is a simple test that gauges the amount of cortisol, an essential hormone, in your body first thing in the morning, just as you're waking up. Cortisol, often referred to as the 'stress hormone', is produced by your adrenal glands and plays a key role in various bodily functions. It helps regulate your metabolism, immune response, and the body's response to stress. It also has a unique daily pattern, typically peaking in the early morning and gradually declining throughout the day. The Cortisol Waking test is a valuable tool in understanding this pattern and ensuring your body's cortisol production is on track.
If Your Levels Are High
High levels of cortisol in your morning test could indicate that your body is under a significant amount of stress. This could be due to a variety of factors, such as physical illness, emotional stress, or certain medications like corticosteroids or hormonal contraceptives. It could also be a sign of a condition called Cushing's syndrome, which is characterized by the overproduction of cortisol by the adrenal glands. Alternatively, it could be due to an adrenal tumor, which can cause the adrenal glands to produce too much cortisol. High cortisol levels could also be a result of poor sleep or shift work, as your body's normal cortisol rhythm can be disrupted by irregular sleep patterns. It's important to note that while high cortisol levels can be indicative of these conditions, they are not definitive and further testing would be needed for a diagnosis.
Symptoms of High Levels
Symptoms of high levels of cortisol could include fatigue, difficulty concentrating, weight gain, particularly around the abdomen, mood swings, high blood pressure, and frequent infections due to a weakened immune system.
If Your Levels are Low
Low levels of cortisol in your morning waking test could indicate that your body isn't producing enough of this crucial hormone. This could be due to conditions like Addison's disease, which affects your adrenal glands' ability to produce cortisol. Certain medications, such as steroid drugs like prednisone, can also lower your body's natural cortisol production. Chronic fatigue syndrome and hypopituitarism, a condition where your pituitary gland doesn't produce enough hormones, can also result in lower cortisol levels. Additionally, external factors like high levels of stress, poor sleep, or a physically demanding lifestyle can impact your cortisol levels. It's important to remember that this is just one piece of the puzzle and other tests may be needed to fully understand your hormone health.
Symptoms of Low Levels
Symptoms of low levels of cortisol could include fatigue, muscle weakness, loss of appetite, weight loss, low blood pressure, and difficulty getting up in the morning.
See References

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[12.] Lopresti AL, Smith SJ, Metse AP, Drummond PD. A randomized, double-blind, placebo-controlled trial investigating the effects of an Ocimum tenuiflorum (Holy Basil) extract (HolixerTM) on stress, mood, and sleep in adults experiencing stress. Front Nutr. 2022 Sep 2;9:965130. doi: 10.3389/fnut.2022.965130. PMID: 36185698; PMCID: PMC9524226.

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[14.] Madison AA, Belury MA, Andridge R, Renna ME, Rosie Shrout M, Malarkey WB, Lin J, Epel ES, Kiecolt-Glaser JK. Omega-3 supplementation and stress reactivity of cellular aging biomarkers: an ancillary substudy of a randomized, controlled trial in midlife adults. Mol Psychiatry. 2021 Jul;26(7):3034-3042. doi: 10.1038/s41380-021-01077-2. Epub 2021 Apr 20. PMID: 33875799; PMCID: PMC8510994.

[15.] Ouanes S, Popp J. High Cortisol and the Risk of Dementia and Alzheimer’s Disease: A Review of the Literature. Frontiers in Aging Neuroscience. 2019;11(43). doi:

[16.] Peters EM, Anderson R, Nieman DC, Fickl H, Jogessar V. Vitamin C supplementation attenuates the increases in circulating cortisol, adrenaline and anti-inflammatory polypeptides following ultramarathon running. Int J Sports Med. 2001 Oct;22(7):537-43. doi: 10.1055/s-2001-17610. PMID: 11590482.

[17.] Remenapp A, Coyle K, Orange T, et al. Efficacy of Withania somnifera supplementation on adult’s cognition and mood. Journal of Ayurveda and Integrative Medicine. 2022;13(2):100510. doi:

[18.] Schutten JC, Joris PJ, Minović I, Post A, van Beek AP, de Borst MH, Mensink RP, Bakker SJL. Long-term magnesium supplementation improves glucocorticoid metabolism: A post-hoc analysis of an intervention trial. Clin Endocrinol (Oxf). 2021 Feb;94(2):150-157. doi: 10.1111/cen.14350. Epub 2020 Oct 26. PMID: 33030273; PMCID: PMC7821302.

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[23.] Ulhaq I, Ahmad T, Khoja A, Islam N. Waking cortisol as an alternative to Short Synecthan test for the diagnosis of primary adrenal insufficiency. Pak J Med Sci. 2019 Sep-Oct;35(5):1413-1416. doi: 10.12669/pjms.35.5.1208. PMID: 31489017; PMCID: PMC6717474.

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[25.] Woldeamanuel YW, Sanjanwala BM, Cowan RP. Endogenous glucocorticoids may serve as biomarkers for migraine chronification. Ther Adv Chronic Dis. 2020 Jul 21;11:2040622320939793. doi: 10.1177/2040622320939793. PMID: 32973989; PMCID: PMC7495027.

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