Adaptive changes in adrenal steroid metabolism under extreme physical and psychological stress: a narrative review

Chronic exposure to sleep deprivation, insufficient recovery, inadequate energy availability, extreme environmental conditions, repetitive high-intensity exercise, and psychological threat can alter hypothalamic-pituitary-adrenal (HPA) axis function. Acute activation of the HPA axis is adaptive, whereas prolonged or repetitive activation may contribute to allostatic load, altered daily glucocorticoid exposure, and changes associated with psychological and metabolic maladaptation.

This narrative review synthesizes evidence on adrenal steroid metabolism under extreme physical and psychological stress, with emphasis on glucocorticoids, mineralocorticoids, and adrenocorticotropic hormone (ACTH)-responsive adrenal androgens, including dehydroepiandrosterone sulfate (DHEA-S) and androstenedione. PubMed and Google Scholar were searched through 22 May 2026. Recent human and military studies were prioritized, and earlier seminal work was included when it provided a mechanistic or historical context not captured by recent literature.

The review describes how acute stress responses may support substrate mobilization and performance, whereas chronic exposure may flatten circadian patterns, alter ultradian glucocorticoid pulsatility, suppress downstream reproductive and metabolic axes, and produce heterogeneous effects on DHEA-S, aldosterone, and neurosteroid pathways. The strongest clinical and military evidence concerns sleep/circadian disruption, energy deficit, and prolonged military training; evidence for direct nutrient-mediated prevention of HPA-axis maladaptation remains preliminary or indirect.

Addressing energy deficit, sleep deprivation and circadian disruption, inadequate recovery, dehydration/heat strain, and clinically relevant nutrient deficiencies may reduce the stressor load that contributes to functional hypercortisolism. Nutritional interventions should focus on correcting deficiencies, maintaining energy, supporting musculoskeletal function, and reducing stress, rather than serving as direct hormonal therapy. Future studies should use standardized steroid sampling, report sex-specific outcomes, and account for energy intake, expenditure, sleep, baseline fitness, and environmental exposures.