High Cortisol Checklists And Why A Video Cannot Run One

The video goes like this. Someone looks into the camera and counts off the signs of high cortisol on their fingers: tired all afternoon, wired at midnight, a puffy face in the morning, a few pounds that won't budge. Most of us tick three out of four, and the comments fill up with people who tick all of them.

High cortisol is a real medical condition, and doctors take it seriously. A video just can't find it. Doctors find it with lab work that takes days. Most of the list in the video describes a busy adult in October.

This page is part of our stress myths series. We take one viral claim at a time and check it against what doctors and the press have said.

What the checklist videos list

Most of these videos list the same things. The Associated Press rounded up the usual set: waking at 3am, a swollen face, weight around the middle. The Guardian quoted one clip that blamed a double chin, puffy eyelids and sagging cheeks on the stress hormone, all in a single sentence.

Here's that list again, with the everyday reasons added back in.

• Tired all afternoon. So is almost everyone who slept six hours and ate lunch at their desk.
• Wired at midnight. Scrolling, a late coffee, and tomorrow's to-do list going round and round.
• A puffy face in the morning. A Baylor dermatologist told CNN that one of the first things she asks about a puffy face is salt. After that, she looks at fluid from diet, health conditions or prescriptions.
• Weight that won't budge. The doctors TIME spoke to listed food, sleep, exercise, medication, menopause and genes as the usual reasons, long before anything rare.
• Waking at 3am. A loud street, needing the bathroom, a warm bedroom, a busy week.

Every item on that list is something people really go through. None of them means much on its own. A checklist can't tell a long week apart from a rare disease, because the two share a lot of the same symptoms.

High cortisol is real, and it's rare

The medical name is Cushing's syndrome. It means the body has had too much of the stress hormone for months at a time. Usually that comes from steroid medicine taken for something else. Less often, it comes from a tumor on the pituitary or adrenal glands.

It's uncommon. The Endocrine Society's 2008 guideline for doctors cites European studies that found two to three new cases per million people per year. The US National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) says about 40 to 70 out of every million people live with the kind the body makes on its own. A pituitary specialist told the Guardian that the kind caused by medicine is far more common.

The signs doctors look for are different from the ones in the videos, too. NIDDK lists a round face, extra fat at the base of the neck, a fatty pad between the shoulders, bruising easily, wide purple stretch marks and weak muscles. They show up together, and they build slowly. An adrenal surgeon told TIME that when the face does change, it happens over months.

Why a video can't check for it

TIME put "we can feel it" on its list of myths. A Cleveland Clinic doctor told the magazine the problem is the stress hormone staying high over a long stretch of time, and that only clinic tests can show it.

Timing is a big part of it. The stress hormone follows a daily rhythm. It climbs fast in the early morning and drops to its lowest point late at night, so one reading taken at the wrong hour tells a doctor very little. An endocrinologist at UTHealth Houston told the AP that a one-off blood test isn't useful for most people, and that birth control pills alone can make a result look high.

The guideline is clear about who should get tested at all. It says to rule out steroid medicine first, and then only test people who have several of the signs, getting worse over time. One puffy Tuesday doesn't count. Neither does a video, no matter how sure the person in it sounds.

How doctors test for it

The 2008 guideline lists the first tests, and a doctor picks one based on the person. These are the three people come across most.

1. A 24-hour urine collection. Everything for a full day goes into a container and off to a lab. It's done at least twice.
2. A late-night saliva sample. It's taken around bedtime, when the body should be at its daily low. This one's done twice too.
3. An overnight dexamethasone suppression test. A small steroid pill at night, then a blood test the next morning to see if the body turned its own supply down the way it should.

If the first result comes back abnormal, the next step is an endocrinologist and a second, different test. NIDDK says doctors usually run two of these before making the call, because no single one is perfect. The Cleveland Clinic adds that it's a hard diagnosis to make, since being tired and gaining weight have so many other causes.

So that's the real process: a doctor, a lab, a few days of samples and a second test to confirm. Ordering a cortisol test online skips most of it. We went through what those kits can and can't tell us on a separate page.

If the list still sounds familiar

It makes total sense to wonder. The videos get so many views because the feelings in them are real, and because a named cause feels better than a vague bad month.

If several of the real signs above have been building for months, the next step is a regular appointment with a primary care doctor. We'd bring a short note of what changed and roughly when. We'd also bring a list of every steroid we use, since the guideline asks doctors to rule those out first. Inhalers, creams, joint injections and nasal sprays all count. An NYU endocrinologist gave the Guardian the short version: if it's a worry, see a doctor.

And if the list only sounds familiar because it's been a looooong week, that's good to know too.

The feeling behind the checklist

The tired and wired feeling those videos are trying to name is real, and we get it as often as anyone. We're Flewd, and we make stresscare bath soaks for those wired-but-tired nights, when we're exhausted by 9pm and still wide awake at 11. Our pouches are formulated with concentrated magnesium chloride, nootropics, aminos and vitamins.

One detail from the testing section stuck with us. Doctors take the saliva sample near bedtime because that's when the body is supposed to be at its quietest. Late evening is also when a warm bath has the most research behind it. A 2019 review pulled together 17 studies of warm baths and showers before bed, and found that as little as 10 minutes in water at 40 to 42.5°C (104 to 108.5°F), one to two hours before bedtime, went along with falling asleep sooner.

Sleep comes up a lot with our customers too. In a survey of more than 3,000 of them over three years, 84% said their sleep improved.*

Our stresscare night at home lays out an evening built around a bath an hour or so before bed, as little as 15 minutes or as long as we like. The other claims we've looked into are on our stress myths page.

*Survey of 3,000+ Flewd customers over 3 years. Individual results may vary.

Questions we get asked

Is high cortisol real?

Yes. It's a real medical condition, usually called Cushing's syndrome, and it's rare. The European studies the Endocrine Society cites found two to three new cases per million people a year.

Can a checklist tell us if we have it?

No. Being tired, a puffy face, weight gain and broken sleep all have lots of everyday causes, and doctors need lab work to tell the difference. Even then, they usually want two separate tests to agree.

Is a puffy face in the morning a sign?

On its own, almost never. The dermatologist CNN spoke to starts with salt, then fluid from diet or prescriptions. The rounder face that comes with Cushing's syndrome builds over months and shows up with other signs.

Is cortisol face the same idea?

Pretty much, with a shorter list. The Guardian quoted an NYU endocrinologist who said it isn't a medical term at all.

Is a warm bath okay for everyone?

We're not doctors, so anyone who's pregnant, taking medication or managing a health condition should check with theirs before starting a new soaking routine.

Where do we start if we're worried?

With a primary care doctor. Bring a note of what changed and when, plus a list of any steroid medicines. The doctor decides if any of the first tests make sense.