Hydrocortisone

Hypothalamic–pituitary–adrenal axis

Glucocorticoid

Hormone

Chronic stress

Endocrinology

Vasopressin

Allostasis

Hypothalamus

Insulin resistance

Adrenal gland

Glucose homeostasis

Circadian rhythm

Allostatic load

Corticotropin-releasing hormone

Internal medicine

Adrenocorticotropic hormone

Physiology

Diabetes mellitus

Immunology

Homeostasis

Medicine

Nature Reviews Endocrinology

The human stress response has evolved to maintain homeostasis under conditions of real or perceived stress. This objective is achieved through autoregulatory neural and hormonal systems in close association with central and peripheral clocks. The hypothalamic–pituitary–adrenal axis is a key regulatory pathway in the maintenance of these homeostatic processes. The end product of this pathway — cortisol — is secreted in a pulsatile pattern, with changes in pulse amplitude creating a circadian pattern. During acute stress, cortisol levels rise and pulsatility is maintained. Although the initial rise in cortisol follows a large surge in adrenocorticotropic hormone levels, if long-term inflammatory stress occurs, adrenocorticotropic hormone levels return to near basal levels while cortisol levels remain raised as a result of increased adrenal sensitivity. In chronic stress, hypothalamic activation of the pituitary changes from corticotropin-releasing hormone-dominant to arginine vasopressin-dominant, and cortisol levels remain raised due at least in part to decreased cortisol metabolism. Acute elevations in cortisol levels are beneficial to promoting survival of the fittest as part of the fight-or-flight response. However, chronic exposure to stress results in reversal of the beneficial effects, with long-term cortisol exposure becoming maladaptive, which can lead to a broad range of problems including the metabolic syndrome, obesity, cancer, mental health disorders, cardiovascular disease and increased susceptibility to infections. Neuroimmunoendocrine modulation in disease states and glucocorticoid-based therapeutics are also discussed. The human stress response has evolved to maintain homeostasis under conditions of stress. This Review outlines the role of the hypothalamic–pituitary–adrenal axis in synchronizing the stress response with circadian regulatory processes and maintaining homeostasis.

The human stress response