Genuinely low cortisol, confirmed by blood tests and a stimulation test, is a medical condition called adrenal insufficiency, and the primary treatment is prescription hydrocortisone taken daily to replace what the adrenal glands can no longer produce. Supplements and lifestyle changes alone cannot substitute for that replacement in someone with a real cortisol deficit. That said, the picture gets more layered when you factor in the different causes of low cortisol, the additional hormones that may need replacing, and the handful of supplements that have legitimate (if limited) roles alongside medical treatment.
Why the Cause of Low Cortisol Matters
Low cortisol is not a single diagnosis. In primary adrenal insufficiency (Addison’s disease), the adrenal glands themselves are damaged, usually by autoimmune attack. Because the whole gland is affected, production of both cortisol and aldosterone drops. Secondary adrenal insufficiency is more common and happens when the pituitary gland stops sending enough of the signaling hormone ACTH to the adrenals. One of the most frequent triggers is prolonged use of prescription steroids like prednisone or dexamethasone for conditions such as asthma, autoimmune disease, or organ transplantation. The body’s feedback loop suppresses its own cortisol production while external steroids are doing the job, and once those steroids are tapered, the system can take months to wake back up. A study tracking patients with steroid-induced adrenal insufficiency found that about 59 percent recovered normal function within one to two years, with the degree of cortisol rise during an initial stimulation test being the strongest predictor of who would bounce back.
1Endocrinology and Metabolism. Recovery of Adrenal Function in Patients with Glucocorticoids Induced Secondary Adrenal InsufficiencyThe distinction between primary and secondary matters for treatment because someone with primary adrenal insufficiency usually needs both cortisol and aldosterone replaced, whereas someone with secondary insufficiency typically needs only cortisol. A stimulated aldosterone cutoff can help clinicians tell them apart when the diagnosis is ambiguous.
2PubMed Central. Primary vs secondary adrenal insufficiency: ACTH-stimulated aldosterone diagnostic cut-off values by tandem mass spectrometryRecovery timelines after stopping steroids are unpredictable. The hypothalamic-pituitary-adrenal axis generally takes 6 to 12 months to recover, but some patients need longer, and a minority never fully recover.
3PubMed Central. Recovery of steroid induced adrenal insufficiencyHydrocortisone Replacement
Oral hydrocortisone is the backbone of treatment for diagnosed adrenal insufficiency. It is bioidentical to the cortisol your body would make on its own. Most adults take a total daily dose split into two or three portions, with the largest dose in the morning to mimic the body’s natural cortisol peak. One study in younger patients with congenital adrenal hyperplasia (a related condition requiring cortisol replacement) found that giving the largest dose in the morning lowered key adrenal hormone markers during the afternoon, while giving the largest dose in the evening lowered those same markers early in the morning. Both schedules produced similar average daily hormone levels and did not differ in effects on blood pressure or sleep quality.
4PubMed Central. Optimizing the Timing of Highest Hydrocortisone Dose in Children and Adolescents With 21-Hydroxylase DeficiencyThe goal is to give just enough cortisol to relieve symptoms and maintain blood pressure, salt balance, and energy without overshooting. Over-replacement carries its own risks, which we will get to. Under-replacement leaves you feeling fatigued, lightheaded, and vulnerable to crisis during illness or injury.
Fludrocortisone for Primary Adrenal Insufficiency
If your adrenal glands are damaged (primary insufficiency), you likely also need a medication called fludrocortisone to replace aldosterone, the hormone that keeps sodium and fluid levels in check. Without it, your body loses salt and water, blood pressure drops, and potassium creeps up. An older but still influential study found that many Addison’s patients on the then-standard fludrocortisone dose of 0.05 to 0.1 mg per day were actually chronically undertreated, showing signs of sodium depletion and elevated renin despite appearing stable. Most patients in that study needed around 0.2 mg daily to maintain proper sodium and water balance, and the best way to gauge the dose was by measuring plasma renin activity along with 24-hour urinary sodium.
5PubMed. Evidence that patients with Addison’s disease are undertreated with fludrocortisoneFludrocortisone is irrelevant for secondary adrenal insufficiency because aldosterone production in those patients is typically preserved (it is regulated more by the renin-angiotensin system than by ACTH).
DHEA as an Add-On
DHEA (dehydroepiandrosterone) is the most abundant steroid the adrenal glands produce, and its levels drop dramatically in adrenal insufficiency. Standard hydrocortisone and fludrocortisone replacement do not restore DHEA levels. A two-year randomized trial in primary adrenal insufficiency showed that daily DHEA supplementation raised circulating androgens to low-normal levels in women, reversed ongoing bone mineral density loss at the hip, and increased lean body mass. One quality-of-life subscale improved as well. However, the trial found no significant benefit for fatigue, cognitive function, or sexual function. Some older women who ended up with higher-than-normal DHEA levels experienced mild androgenic side effects like acne and changes in body hair.
6PubMed Central. Long-term DHEA replacement in primary adrenal insufficiency: a randomized, controlled trialA typical replacement dose is 25 to 50 mg taken once in the morning. The evidence is mixed enough that not all endocrinologists prescribe it routinely, and its effects on well-being seem clearer in studies that run long enough and enroll enough patients.
7PubMed. DHEA: why, when, and how much–DHEA replacement in adrenal insufficiencySick-Day Rules and Adrenal Crisis Prevention
If you are on hydrocortisone replacement, the most dangerous situation you can face is an adrenal crisis, which happens when physical stress outstrips your cortisol supply. This is not a theoretical risk. Roughly one in six to twelve adrenal insufficiency patients ends up hospitalized for a crisis at least once a year, and about one in 200 dies from one that could have been prevented.
8Journal of the Endocrine Society. Exploring Patient And Parent Perceptions Of Administering Hydrocortisone Injection During Adrenal Crisis: A Cross-Sectional StudyPrevention hinges on “sick-day rules” that every patient and their family members should know:
- Mild illness: Double your normal oral hydrocortisone dose when you have a fever, an infection requiring antibiotics, or any illness that puts you in bed. Keep a seven-day emergency supply of extra tablets on hand.
- Severe illness or vomiting: If you cannot keep pills down or are facing surgery, trauma, or persistent vomiting, inject 100 mg hydrocortisone intramuscularly, intravenously, or subcutaneously. After the initial injection, follow with 200 mg over the next 24 hours, either by continuous infusion or by 50 mg injections every six hours.
Pharmacokinetic modeling has shown that continuous intravenous infusion of 200 mg hydrocortisone over 24 hours, preceded by an initial 50 to 100 mg bolus, is the approach that most closely replicates the cortisol levels healthy people produce during major stress. Intermittent bolus doses, whether oral or injected, create peaks and troughs that leave windows of under-replacement and risk of crisis.
10The Journal of Clinical Endocrinology & Metabolism. Prevention of Adrenal Crisis: Cortisol Responses to Major Stress Compared to Stress Dose Hydrocortisone DeliveryA persistent practical problem is that emergency injection kits are cumbersome. While about 70 percent of patients own one, only 19 percent have ever been trained to use it, and the devices can require up to 20 steps to assemble and inject.
8Journal of the Endocrine Society. Exploring Patient And Parent Perceptions Of Administering Hydrocortisone Injection During Adrenal Crisis: A Cross-Sectional StudyLicorice Root and Cortisol Metabolism
Licorice root is the one widely available botanical with a well-documented mechanism for raising active cortisol in the body. Its active compounds, glycyrrhizic acid and glycyrrhetinic acid, block an enzyme called 11-beta-hydroxysteroid dehydrogenase. That enzyme normally converts cortisol into its inactive form, cortisone. When the enzyme is inhibited, cortisol hangs around longer and in higher concentrations, exerting stronger effects on both glucocorticoid and mineralocorticoid receptors.
11PubMed. Licorice inhibits 11 beta-hydroxysteroid dehydrogenase messenger ribonucleic acid levels and potentiates glucocorticoid hormone actionThis might sound appealing if your cortisol is on the low side, but the mechanism is a double-edged sword. Because cortisol is also a potent activator of mineralocorticoid receptors once the protective enzyme is removed, licorice consumption can cause a syndrome that looks like aldosterone excess even when aldosterone levels are actually low. The result is high blood pressure, low potassium, and fluid retention. Case reports document this happening even with moderate intake of licorice-containing herbal teas, and the risk is amplified if a person is also taking certain diabetes medications.
12PubMed Central. A Case of Hypokalemia Caused by the Consumption of Licorice-Containing Herbal Tea 13PubMed Central. Licorice Root Supplement As A Cause Of Hypokalemic Hypertension
For someone with confirmed adrenal insufficiency already on hydrocortisone, adding licorice root does not replace what is missing. It just slows the breakdown of whatever cortisol is already present. And the cardiovascular side effects make it a poor substitute for proper medical treatment. If you are considering licorice supplements, your doctor needs to know, especially if you have any history of high blood pressure or heart issues.
Vitamins and Micronutrient Support
Vitamin C concentrates heavily in the adrenal glands, more so than in almost any other organ. In mammals that can synthesize their own vitamin C (unlike humans), the stress response triggers increased vitamin C production alongside cortisol and adrenaline. These three compounds appear to work together to maintain blood pressure, support immune function, and limit oxidative damage. In critically ill patients, vitamin C supplementation seems to support the stress response and may improve survival, though this evidence comes mostly from the setting of sepsis and severe illness, not everyday low cortisol.
14PubMed Central. Vitamin C: an essential “stress hormone” during sepsisPantothenic acid (vitamin B5) is another nutrient linked to adrenal steroidogenesis. It is a precursor to coenzyme A, which is essential for the biochemical steps that produce steroid hormones. An animal study found that rats supplemented with pantothenic acid had higher baseline levels of corticosterone (the rodent equivalent of cortisol) and a stronger hormonal response when stimulated with ACTH.
15PubMed. Effects of pantothenic acid supplementation on adrenal steroid secretion from male ratsNeither vitamin C nor pantothenic acid can replace hydrocortisone in someone with diagnosed adrenal insufficiency. But ensuring you are not deficient in either one is reasonable general advice, especially since both are water-soluble, inexpensive, and carry very low risk at normal supplemental doses. Think of them as supporting the machinery rather than providing the product.
What About Ashwagandha and Rhodiola?
These two herbs appear on virtually every “adrenal support” supplement list, but their actual effect on cortisol goes in the opposite direction from what someone with low cortisol needs. Multiple meta-analyses of ashwagandha trials show that it significantly lowers serum cortisol levels compared to placebo, with the effect emerging after about eight weeks of daily use.
16PubMed Central. Effects of Ashwagandha Supplements on Cortisol, Stress, and Anxiety Levels in Adults: A Systematic Review and Meta-Analysis 17PubMed. Effects of Ashwagandha (Withania Somnifera) on stress and anxiety: A systematic review and meta-analysis
Rhodiola rosea follows a similar pattern. A trial in people with burnout-related fatigue found that rhodiola significantly decreased cortisol response to awakening stress, not increased it. The European Medicines Agency has approved rhodiola as an adaptogen for “stress,” and reviews describe it as influencing the release of stress hormones and supporting energy metabolism, but the overall direction of that influence is toward blunting cortisol, not boosting it.
18PubMed. A randomised, double-blind, placebo-controlled, parallel-group study of the standardised extract shr-5 of the roots of Rhodiola rosea in the treatment of subjects with stress-related fatigue 19PubMed. Stress management and the role of Rhodiola rosea: a review
The marketing confusion comes from the word “adaptogen,” which is used to describe herbs that supposedly help the body “balance” its stress response. In practice, the trials show that adaptogens like ashwagandha and rhodiola reduce cortisol in people with elevated or normal levels. They do not raise it in people who are deficient. If your cortisol is already low, these supplements could theoretically make things worse. Anyone with confirmed adrenal insufficiency should be cautious about taking them without discussing it with an endocrinologist.
Panax ginseng, another popular adaptogen, has been studied for its cortisol effects, but the results are even less clear. Short trials in healthy fatigued adults have shown either no significant effect or a slight, non-significant trend toward raising cortisol, which is not enough evidence to recommend it for someone with a genuine cortisol deficit.
20Journal of Functional Foods. The effect of adaptogenic plants on stress: A systematic review and meta-analysisThe “Adrenal Fatigue” Question
A large number of people searching for ways to raise cortisol have been told, usually by alternative health practitioners, that they have “adrenal fatigue,” a condition in which chronic stress has supposedly worn out the adrenal glands so they can no longer keep up with cortisol demand. A systematic review published in BMC Endocrine Disorders looked at all available studies that attempted to link mild adrenal hormone changes with symptoms attributed to “adrenal fatigue” and concluded that there is no substantiation for it as an actual medical condition.
21PubMed Central. Adrenal fatigue does not exist: a systematic reviewThis does not mean people with fatigue, brain fog, and low energy are imagining their symptoms. It means labeling those symptoms as “adrenal fatigue” leads to the wrong diagnostic path and the wrong treatment. True adrenal insufficiency is diagnosed with specific lab work, including morning cortisol levels and ACTH stimulation tests. More modern assays have actually lowered the diagnostic cutoff for stimulated cortisol to around 14 to 15 micrograms per deciliter, down from the older threshold of 18 micrograms per deciliter. This change means some cases that would have been missed by older tests are now caught.
22PubMed Central. New Cutoffs for the Biochemical Diagnosis of Adrenal Insufficiency after ACTH Stimulation using Specific Cortisol AssaysIf you suspect your cortisol is low, the right first step is getting tested properly, not self-treating with adaptogen stacks from a wellness brand. The symptoms of adrenal insufficiency (exhaustion, dizziness on standing, salt cravings, unexplained weight loss) overlap heavily with dozens of other conditions, from thyroid disease to iron deficiency to depression. Only lab confirmation makes the diagnosis.
Overtraining and Blunted Cortisol
One scenario that sits in a gray zone between healthy and clinically insufficient is overtraining syndrome in athletes. When people exercise far beyond their recovery capacity for weeks or months, their hormonal stress response can become blunted. Research comparing overtrained athletes with healthy athletes and sedentary controls found that overtrained athletes had a markedly lower cortisol response during an insulin tolerance test and a lower cortisol awakening response in the morning. Healthy athletes, by contrast, showed the highest cortisol responses of any group.
23PubMed Central. Hypothalamic-Pituitary-Adrenal (HPA) Axis Functioning in Overtraining Syndrome: Findings from Endocrine and Metabolic Responses on Overtraining Syndrome (EROS)—EROS-HPA AxisThis blunted response looks somewhat like secondary adrenal insufficiency on testing, but it typically resolves with rest and recovery rather than lifelong hormone replacement. The treatment, if you can call it that, is pulling back on training volume, sleeping more, and eating enough. No supplement fixes overtraining if the training load does not change.
Bone Health on Long-Term Hydrocortisone
People who take hydrocortisone for years face a genuine trade-off. The medication keeps them alive and functional, but even at replacement doses, cortisol and its metabolites can suppress bone formation. A study of patients on hydrocortisone therapy found that nighttime cortisone levels and total urinary cortisol metabolites were inversely correlated with bone formation markers, meaning higher exposure was associated with less new bone being built.
24PubMed Central. The contribution of serum cortisone and glucocorticoid metabolites to detrimental bone health in patients receiving hydrocortisone therapyThis is one reason endocrinologists aim for the lowest effective hydrocortisone dose and why newer modified-release formulations, designed to deliver cortisol more gradually and reduce overnight exposure, are attracting interest. For patients on replacement therapy, periodic bone density scans are part of standard monitoring, along with attention to vitamin D and calcium intake. DHEA supplementation, as noted earlier, showed some protective effect on hip bone density in one trial, which may be an additional argument for adding it in certain patients.