If you live with chronic pain, you may have wondered about the connection between cortisol and chronic pain, particularly if you’ve noticed that stress seems to make your symptoms worse.
Maybe your pain flares after a particularly stressful week. You sleep badly for a few nights and suddenly everything hurts more. Or you’ve been told that your body is “stuck in stress mode” and that high cortisol could be contributing to your symptoms.
So the conclusion seems fairly logical: if stress increases cortisol and stress makes pain worse, perhaps you need to lower your cortisol.
But there’s an important piece of that story that often gets missed.
Cortisol isn’t simply a stress hormone that your body would be better off without. It also plays an important role in regulating inflammation – one of the very processes that can contribute to pain.
And this is where the relationship between cortisol and chronic pain becomes much more interesting.
In some people with chronic pain, research has found higher or altered cortisol activity. In others, particularly in certain persistent pain conditions, researchers have found lower cortisol levels, flatter daily rhythms or a blunted cortisol response. Chronic pain itself may also change how the body’s stress-response system functions over time.
So when I see someone with persistent pain alongside symptoms such as fatigue, poor sleep, reduced resilience to stress or inflammatory symptoms, I’m not automatically thinking how do we lower her cortisol?
I’m more interested in: What has been happening between her pain, inflammation and stress-response system – and does that give us another clue about why her pain is persisting?
Because when it comes to cortisol and chronic pain, the goal isn’t necessarily to get cortisol “down”. First, we need to understand what it’s doing.
What Is Cortisol and What Does It Actually Do?
If you’ve been trying to reduce stress because of your pain, you may have started thinking of cortisol as something you need less of.
And that’s understandable. Cortisol is usually introduced as the “stress hormone”, and high cortisol is blamed for everything from poor sleep and anxiety to weight gain, hormonal symptoms and inflammation.
But your body isn’t producing cortisol by mistake.
You need cortisol – particularly when your body is under demand from stress.
Cortisol is produced by your adrenal glands as part of the hypothalamic-pituitary-adrenal (HPA) axis, the communication system between your brain and adrenal glands that helps your body respond and adapt to what’s happening around, and within, you.
That might be psychological stress. But it could also be pain, illness, inflammation, disrupted sleep or changes in blood sugar. Your body doesn’t neatly separate the stressful week at work from the fact that you’ve also been waking at 2 am in pain.
Cortisol helps make energy available when you need it, supports blood pressure and your sleep-wake cycle, and helps regulate immune and inflammatory activity. It also follows a natural daily rhythm, generally rising around waking and gradually falling towards night.
So when I look at cortisol clinically, I’m not simply looking for a number that’s “too high” or “too low”. I’m interested in whether the response makes sense for what that person’s body is dealing with.
Someone living with persistent pain, sleeping poorly and managing an inflammatory condition is experiencing a very different physiological demand from someone who is otherwise well but has had a stressful month at work. Both women might describe themselves as “stressed”, but what’s driving that stress – and how their bodies are responding to it – may be completely different.
And this is where the usual advice to simply “lower your cortisol” starts to fall apart. Because one of cortisol’s normal jobs is particularly relevant when you’re in pain: helping your body regulate inflammation.
How Are Cortisol and Chronic Pain Connected?
If you’ve noticed that your pain gets worse when you’re stressed, there’s a good reason for that.
Stress can increase inflammation and make your nervous system more sensitive to pain. It can also disrupt your sleep, affect your blood sugar and make it harder for your body to recover.
So reducing stress can absolutely be helpful. But here’s the part that often gets missed.
Cortisol, the hormone we associate so strongly with stress, is also one of your body’s natural ways of keeping inflammation in check.
At first, that sounds contradictory. If stress can increase inflammation, how can a stress hormone be anti-inflammatory? It’s because when your body creates an inflammatory response, it also needs mechanisms for controlling that response. Cortisol is one of them.
Cortisol helps regulate inflammatory and immune activity so that inflammation doesn’t become bigger or continue for longer than it needs to. This is also why synthetic glucocorticoid medications, which mimic many of cortisol’s effects, can be such powerful anti-inflammatory drugs. This matters when pain or inflammation isn’t a short-lived event.
If your body has been dealing with an inflammatory condition, persistent pain or another ongoing physiological stressor for months or years, your stress-response system has been part of that picture too. And over time, the way that system responds can change.
That’s important because if cortisol is helping your body keep inflammation in check, a lower or blunted cortisol response may, in some people, mean there is less of that natural anti-inflammatory signalling available when it’s needed.
In other words, pain and inflammation aren’t only associated with high cortisol. In some chronic pain conditions, lower cortisol activity has also been associated with greater inflammation, pain or pain sensitivity.
Which raises a very different question:
What if the problem isn’t simply that stress is pushing cortisol too high, but that over time the cortisol response is no longer matching what your body needs?
What Happens to Cortisol During Chronic Stress and Pain?
Your stress-response system is designed to help you adapt.
You have a demanding week, get an infection, miss a few nights of sleep or experience a pain flare, and your body adjusts to help you cope with what’s happening.
Usually, the demand passes and your body gets a chance to recover. But for many women with chronic health conditions, life doesn’t always happen in such neat little chapters.
It might be years of painful periods and inflammatory flares. Sleep that’s repeatedly interrupted by pain. Surgery followed by recovery, followed by another flare. Pushing through exhaustion because there are still children to look after, meetings to attend and a life that doesn’t stop simply because your body is struggling. There may never have been one dramatic period where everything fell apart. You just gradually stopped bouncing back the way you used to.
A busy weekend now takes days to recover from. Exercise that once gave you energy leaves you exhausted. Your pain seems easier to trigger. You wake tired after what should have been enough sleep. Perhaps you’ve even found yourself saying, “I don’t understand why my body can’t handle things anymore.”
This is where cortisol can become another useful clue.
When the body has been responding to ongoing stress, pain or illness for a long time, the cortisol response can change. Research in some chronic pain conditions has found lower cortisol levels, flatter daily cortisol patterns or a less robust cortisol response.
One way to picture this is the body turning down the volume on a stress response that has been switched on too often. It isn’t that you’ve “used up” your cortisol or that your adrenal glands have simply stopped working. Rather, the body can change how strongly it signals for cortisol and how much it produces at different times of the day.
And now the anti-inflammatory piece we talked about earlier becomes much more relevant.
If cortisol is one of the ways your body helps keep inflammation in check, what happens when that cortisol response is no longer as strong as it once was, but the pain or inflammation hasn’t gone away?
For some women, that may be one piece of a much bigger picture of increasing fatigue, slower recovery and pain or inflammatory symptoms that have become easier to trigger.
It doesn’t mean low cortisol explains everything. But it can help explain why simply telling someone with this pattern to “reduce your stress” can feel so inadequate. Because sometimes the more useful question isn’t how much stress is in your life.
It’s why your body no longer seems to recover from it the way it once did.
The Cortisol-Progesterone Connection: Why It Matters for Reproductive Conditions
If you’re living with endometriosis, adenomyosis or another oestrogen-dependent reproductive condition, changes in your cortisol response may affect pain through more than one pathway.
We’ve already seen that cortisol helps regulate inflammation. But your stress-response system also communicates with your reproductive hormones, including progesterone.
And that matters because progesterone provides another important brake on inflammation.
Endometriosis and adenomyosis are influenced by oestrogen. Oestrogen isn’t inherently bad, but in these conditions it can stimulate endometrial-like tissue and contribute to inflammatory activity.
Progesterone helps counter some of those effects, while also having anti-inflammatory actions of its own.
So if your cortisol response has become less robust after a long period of pain, inflammation and other ongoing demands, there may already be less of cortisol’s anti-inflammatory influence available when your body needs it.
At the same time, prolonged stress physiology can affect the hormonal signalling involved in ovulation. And ovulation is what gives you the large rise in progesterone during the second half of your cycle.
Then if ovulation becomes delayed, disrupted or doesn’t happen, progesterone production can change too.
This isn’t because your body is simply “burning through progesterone” to make cortisol. Cortisol and progesterone are both steroid hormones made from cholesterol through overlapping pathways, but the relationship is more complex than one hormone stealing from another.
The more useful way to think about it is this:
if your cortisol response is no longer providing the same anti-inflammatory support, while disrupted ovulation is also reducing progesterone’s ability to counter oestrogen-driven and inflammatory activity, two of the systems that normally help put the brakes on inflammation may be affected at the same time.
For someone with an oestrogen-dependent inflammatory condition, that may matter for your pain.
Which is why, when your pain, energy and cycle all start changing together, the timing itself can be an important clue about what your body is struggling to regulate.
Can You Test Cortisol Levels?
Yes, but the way you test it changes what you can see.
A standard blood cortisol test, which your GP may order, gives you a snapshot of cortisol at one point in time. That can be useful when investigating significant adrenal or endocrine dysfunction.
But if you’re trying to understand why your pain sits alongside fatigue, poor recovery, disrupted sleep or hormonal changes, one number may not tell you enough.
Functional tests such as the DUTCH test look at cortisol across the day and also measure cortisol metabolites. This can give a broader picture of your daily rhythm, overall cortisol output and how cortisol is being metabolised and converted between cortisol and cortisone.
That means your free cortisol can sometimes look relatively normal, while the wider pattern suggests that overall metabolised cortisol output is low, or that cortisol is being cleared or converted differently.
So the goal isn’t simply to find out whether your cortisol is “high” or “low”.
It’s to understand whether the pattern fits with what your body has been dealing with, and whether it helps explain why your pain, energy and recovery have changed.
What Can Help When Cortisol, Inflammation and Pain Are Connected?
If cortisol looks like part of your pain picture, the answer usually isn’t to simply “raise” or “lower” cortisol.
The more useful question is: what is keeping your stress-response system under pressure in the first place?
That might include ongoing pain itself, poor sleep, blood sugar instability, under-eating, recurrent illness, psychological stress or persistent inflammation.
For one woman, improving sleep and stabilising blood sugar may take pressure off the system. For another, the bigger issue may be hormonal disruption, ongoing inflammation or pain that is continually activating the stress response.
But that doesn’t mean you have to wait until every underlying driver is resolved before you can start feeling better.
Depending on your cortisol pattern, certain adaptogenic herbs may be useful, alongside nutrients involved in adrenal steroid hormone production, such as vitamin B5 and other key micronutrients. These can be used to support the stress-response system while the deeper drivers are being addressed.
And because cortisol is involved in regulating inflammation, sleep, energy and recovery, supporting that response may also help make pain less easy to trigger and give you more capacity to function while the underlying work is happening.
The aim is to do both: give you some quality of life back now, while still understanding what has been keeping your body in this pattern in the first place.
The Bigger Picture
If stress makes your pain worse, the answer isn’t always to assume your cortisol is too high.
Sometimes the more useful question is whether your stress-response system is still responding appropriately to what your body is dealing with.
If chronic pain is showing up alongside fatigue, poor recovery, disrupted sleep or hormonal changes, this is the kind of pattern I look at in consultation.
If you’d like help understanding what may be driving your pain, you can book a consultation with me here.
Warmly,
References
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https://pubmed.ncbi.nlm.nih.gov/26654189/ - Úbeda-D’Ocasar, E., Jiménez Díaz-Benito, V., Gallego-Sendarrubias, G. M., Valera-Calero, J. A., Vicario-Merino, Á., & Hervás-Pérez, J. P. (2020). Pain and cortisol in patients with fibromyalgia: Systematic review and meta-analysis. Diagnostics, 10(11), 922.
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https://pubmed.ncbi.nlm.nih.gov/15288182/ - Toufexis, D., Rivarola, M. A., Lara, H., & Viau, V. (2014). Stress and the reproductive axis. Journal of Neuroendocrinology, 26(9), 573-586.
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