What is cortisol and the role it plays in the body?
Cortisol is a stress hormone. We all have cortisol, and in situations of stress, our cortisol levels will be higher. Cortisol has multiple functions in the body and affects many organs. It helps keep your metabolism normal and helps you respond to stressors; for example, if you become ill, your body will make more cortisol to help you get through that illness. If someone undergoes surgery, their cortisol will be higher. It also influences your glucose metabolism, bones, muscles, and brain.
Cortisol follows what we call a circadian rhythm, which means it varies throughout the day. Generally, when we wake up, our stress levels and cortisol are higher, and the lowest cortisol levels should be at night when we are relaxing to go to bed.
The problem is when cortisol becomes too high or too low in times that it is not supposed to be high or low. When that happens, the body starts showing the effects of low or high cortisol.
You mentioned the body starts to show the effects of low or high cortisol. Can you describe what that can look like?
Patients with very low cortisol will tend to have gastrointestinal symptoms such as diarrhea, belly pain, and vomiting. Their blood pressure and blood sugar drops, and electrolytes in their blood will be affected. It can lead to people feeling extremely weak and not being able to function normally.
On the other hand, when it comes to having excessively high cortisol, it can lead to having decreased bone density, increased risk of having diabetes and high blood sugar, insulin resistance, weight gain — particularly in the abdomen and face — and muscle wasting, leading to thin arms and legs. People may experience weakness, metabolic changes, and increased cardiovascular risks. When the body persistently has too much cortisol, this can lead to a condition called “Cushing’s syndrome.”
What are the factors that can affect your cortisol and lead to excessive levels of it?
Many day-to-day things can affect your cortisol levels, such as stress, getting sick, the time of day, and so on. Other factors like pregnancy can lead to someone’s cortisol levels being higher. In these cases, patients will often not experience symptoms of high cortisol.
If a person does persistently have high cortisol levels, it may be due to a tumor that is making too much cortisol. This is called endogenous Cushing’s syndrome, which is very rare. Anytime we refer to Cushing’s disease, which is a type of Cushing’s syndrome, we are referring to when a pituitary tumor is causing the excessive cortisol levels. Common symptoms of this include weight gain, decreased muscle mass, developing a round face that is sometimes called a “moon face,” and developing a hump that appears on the back of the neck, also called a “buffalo hump.”
There is also exogenous Cushing’s syndrome, which is not caused by the body making too much cortisol but is actually primarily caused by taking steroids, whether it be through pills, injections, inhalers, or creams. There are multiple medical problems that require steroid treatments, such as if someone has a respiratory infection or autoimmune problem. This exposure to steroids can lead to excessive cortisol in the body. Typically, this is the most common cause of Cushing’s syndrome.
Pathologic conditions can also lead to excessive cortisol in the body, such as depression, malnutrition, and problems with alcohol use. In those situations, if we treat the conditions — such as depression or malnutrition — then the cortisol level will get better. In endocrinology, we call this pseudo-Cushing's syndrome, because the excessive cortisol is related to some underlying condition and not a tumor.
Can cortisol levels affect your face, such as how puffy it is?
Yes, persistently elevated levels of cortisol can lead to weight gain in the face. But it can be hard to determine if a person’s round face is because of high cortisol because there are multiple factors that can cause facial swelling. I recommend looking at whether you have multiple symptoms — not just a round face — of cortisol excess; if so, you should be assessed by a physician.
Other symptoms to look out for include developing a buffalo hump, increased fat in the stomach, thinning of the arms and legs, wide purple stretch marks on the stomach and armpits, easier bruising, increased acne and hair growth, and other metabolic problems such as hypertension, diabetes, heart disease, and osteoporosis.
Cortisol face is also sometimes called ‘moon face.’ What do these terms mean medically?
Cortisol face and moon face are not medical terms. The medical term is moon facies (caused by fat accumulation in the face) or facial plethora (caused by increased blood flow to the face and facial swelling), which is a relatively common symptom of Cushing’s syndrome where there is weight gain in the face that generally also comes with redness in the face.
However, if a patient comes to me and says they believe they have developed cortisol face or moon face, then I think it’s reasonable to test their cortisol levels.
At what point should someone be concerned about their facial swelling? If someone feels that they have had a considerable increase in how puffy their face is, what should they do?
If the only symptom a person has is developing a rounder face, then it is hard to say that their facial swelling is due to high cortisol. The majority of patients who have Cushing’s syndrome will have other symptoms.
I think it’s important to look for not only having a change in the shape of your face for a day or so, but look at whether it has been a persistent change in your face and if you have other symptoms associated with Cushing’s syndrome. If this is the case, then talk to your primary care physician. Screening tests are really useful, and we have three screening tests for high cortisol. One of them is a blood test that you do in the morning after taking a steroid pill the night before, and that can give us insight into whether you have elevated cortisol levels.
Some social media users claim that they were able to stop having “cortisol face” by lowering their cortisol levels through facial exercises, stress reduction, or consuming certain foods and drinks like apple cider vinegar and magnesium. Is it possible to reduce or re-balance your cortisol levels?
If someone has noticed their round face or facial swelling goes away after making certain dietary changes or taking natural supplements, then, in my opinion, that means their round face was less likely to be related to high cortisol.
I am not aware of any diet that can help balance someone’s cortisol levels. However, making lifestyle changes that involve more exercise, less stress, and less alcohol intake are always good practices to help keep your cortisol from getting too high.
Bottom line: Does the average healthy person need to worry about “cortisol face,” or do you think this is an overhyped trend on social media?
If you have concerns that you have cortisol face or moon face and may be experiencing excessively high cortisol levels, share those worries with your doctors.
As physicians, I think we need to acknowledge what patients are concerned about. A colleague once told me that if you diagnose Cushing's syndrome in a person in an early manner and provide appropriate treatment, you pretty much save their life — and that's because you do not want to miss that person who has had high cortisol from a tumor that you can cure.
Any one symptom may be taken differently by two different people, and it’s important that I listen to what my patients tell me. If there is a concern that there is a cortisol problem, then that should be evaluated and screened. And if the results show normal levels, then I can reassure my patient that their cortisol levels are normal.
