Adrenal PCOS Symptoms: Is Stress Driving Your Hormone Imbalance?

Discover Ovastart, our inositol-based supplement designed for women with PCOS.

You've tried the low-carb diet. You've committed to the HIIT workouts. You've bought the supplements promised to "balance your hormones." And yet… nothing has changed. Your acne persists, your hair continues to thin at the temples, and you're exhausted despite sleeping eight hours a night.

Here's what nobody told you: if you have Adrenal PCOS, the standard PCOS advice might actually be making things worse.

Adrenal PCOS is the "invisible" subtype affecting roughly 10% of women with PCOS (1). Unlike the more common insulin-resistant type, it's driven primarily by stress and dysfunction in your body's stress-response system. The catch? Most doctors aren't screening for it, and most PCOS content online doesn't address it.

If you have normal insulin levels but still struggle with androgen-related symptoms like persistent acne and hair loss, this article is for you. We'll walk you through the unique signs of Adrenal PCOS, explain the science behind it, and share a recovery strategy that actually works for this subtype.

Adult-onset acne – Often appearing on the jawline, chin, and temples. This acne may have started or worsened in your 20s or 30s, rather than during puberty.

Temple and frontal hair thinning – Hair loss concentrated around the hairline and temples, creating a receding pattern similar to male-pattern baldness.

"Wired but tired" energy – You feel physically exhausted but mentally wired, making it difficult to wind down at night despite feeling drained during the day.

Poor stress resilience – Small stressors feel overwhelming. You may find yourself snapping easily, feeling anxious over minor issues, or unable to "bounce back" from challenges.

Sleep disturbances – Difficulty falling asleep, waking frequently during the night, or waking up feeling unrefreshed. Many women with Adrenal PCOS report waking between 2-4 AM. Sleep quality has a profound impact on hormonal balance, making this symptom particularly important to address.

Normal or low BMI with PCOS symptoms – You don't struggle with weight gain or insulin resistance, yet you still have irregular cycles, acne, and hair loss.

Symptoms worsen with intense exercise or fasting – Rather than improving with strict diet and exercise regimens, your symptoms actually get worse when you restrict food or push your body hard.

If multiple items on this list resonate with you, it's worth investigating whether elevated DHEAS is at the root of your symptoms.

The Lab Test Guide: DHEAS vs. Testosterone

One of the most frustrating aspects of Adrenal PCOS is that it's frequently missed during standard hormone testing. Here's what you need to know about the labs that matter.

Why DHEAS is the "Smoking Gun"

DHEAS is produced almost exclusively by the adrenal glands, making it the definitive marker for adrenal androgen excess (6). Unlike testosterone, which can come from either the ovaries or adrenal glands, DHEAS points directly to adrenal involvement.

DHEAS vs DHEA: Why the "S" Matters

You may have seen both DHEA and DHEAS mentioned in hormone discussions. While related, they're not interchangeable for diagnostic purposes. DHEAS (dehydroepiandrosterone sulfate) is the sulfated, more stable form of DHEA. This stability is crucial: DHEAS levels remain relatively constant throughout the day, making it a reliable marker regardless of when you test (7).

DHEA, by contrast, fluctuates significantly with circadian rhythms and stress responses, making it less useful for diagnosis. When your doctor orders testing for adrenal androgen excess, they should specifically request DHEAS—not DHEA—to get an accurate picture of your adrenal function.

Normal DHEAS levels vary by age and laboratory, but generally:

• Normal range: 35-430 µg/dL for women of reproductive age

• Elevated in Adrenal PCOS: Often above 200-250 µg/dL, though even high-normal levels can be problematic in the context of other symptoms

Crucially, DHEAS can be elevated even when total testosterone and free testosterone are within normal limits. This is why many women with Adrenal PCOS are told their hormones are "fine" despite experiencing clear androgen-related symptoms (8).

Ruling Out NCAH: An Essential Step

Before confirming Adrenal PCOS, it's critical to rule out Non-Classical Congenital Adrenal Hyperplasia (NCAH), a genetic condition that can present almost identically to Adrenal PCOS (9).

NCAH is caused by enzyme deficiencies (most commonly 21-hydroxylase deficiency) that lead to excessive androgen production by the adrenal glands. Women with NCAH experience the same symptoms—acne, hair thinning, irregular cycles, elevated DHEAS—but the underlying mechanism and treatment approach differ significantly.

The key difference: NCAH requires medical management and monitoring by an endocrinologist, as it can affect cortisol production and stress response in ways that require specific interventions. Some women with NCAH may need low-dose glucocorticoid therapy, particularly if planning pregnancy (10).

The screening test is simple: 17-hydroxyprogesterone (17-OHP), measured in the morning. Elevated baseline 17-OHP (typically >200 ng/dL) suggests NCAH and warrants further testing with an ACTH stimulation test to confirm the diagnosis.

If you have elevated DHEAS, insist on 17-OHP testing. It's the only way to definitively distinguish between Adrenal PCOS and NCAH, ensuring you receive the appropriate care for your specific condition.

Why Your Insulin Might Be Normal

Unlike classic insulin-resistant PCOS, Adrenal PCOS is not primarily driven by insulin dysfunction. This means your fasting insulin, glucose, and HbA1c may all come back completely normal. You might even pass an oral glucose tolerance test with flying colours.

This is the missing link for many patients—and the reason standard PCOS dietary advice (very low carb, intermittent fasting, keto) often backfires. These approaches are designed to improve insulin sensitivity, but in Adrenal PCOS, they can actually increase cortisol and worsen androgen production (11).

Lab "Cheat Sheet" to Request from Your Doctor

When discussing testing with your healthcare provider, request:

• DHEAS (the most important marker for Adrenal PCOS)
• Total testosterone and free testosterone (to compare ovarian vs. adrenal contribution)
• 17-hydroxyprogesterone (17-OHP) (to rule out NCAH—essential before confirming Adrenal PCOS)
• Fasting insulin and glucose (to rule out insulin resistance)
• Morning cortisol (to assess baseline stress hormone levels)

Ideally, testing should be done in the morning (between 8-10 AM) when hormone levels are most stable and representative.

Why Stress "Breaks" the Ovarian-Adrenal Connection

To understand Adrenal PCOS, you need to understand the HPA axis—the hypothalamic-pituitary-adrenal axis, your body's central stress-response system.

Here's how it works in a healthy system:

1. The hypothalamus (in your brain) senses stress and releases CRH (corticotropin-releasing hormone)

2. The pituitary gland responds by releasing ACTH (adrenocorticotropic hormone)

3. The adrenal glands respond to ACTH by producing cortisol (the primary stress hormone) and small amounts of DHEAS

In Adrenal PCOS, this system becomes dysregulated. Chronic activation of the HPA axis, whether from emotional stress, physical stress (like overtraining), or metabolic stress (like undereating), leads to persistently elevated ACTH. This signals the adrenal glands to continuously produce not just cortisol, but also excessive amounts of DHEAS (12).

Here's the problem: DHEAS converts to more potent androgens in peripheral tissues, leading to acne, hair loss, and other symptoms. Meanwhile, chronically elevated cortisol disrupts ovulation, contributing to irregular cycles even when insulin is normal (13).

Research has shown that women with elevated DHEAS often have exaggerated ACTH responses to stress, suggesting their adrenal glands are hypersensitive to stress signals (14). This creates a vicious cycle: stress triggers DHEAS production, which worsens symptoms, which creates more stress.

Additional factors that can dysregulate the HPA axis include:

• Sleep deprivation: Even one night of poor sleep can significantly increase cortisol and ACTH the following day
• Undereating or extreme calorie restriction: The body perceives this as a threat, activating stress pathways
• Over-exercising without adequate recovery: High-intensity exercise stimulates cortisol and ACTH; without rest, this becomes chronic
• Psychological stress: Chronic anxiety, trauma, or high-pressure environments keep the HPA axis in overdrive

Recovery Strategy: Beyond the Standard PCOS Diet

If you have Adrenal PCOS, the path to healing looks different from conventional PCOS management. The goal is not to restrict or push harder. It's to calm your nervous system and support your body's natural stress-recovery mechanisms.

The "Anti-Stress" Nutrition Plan

The primary nutritional goal in Adrenal PCOS is blood sugar stability and adequate nourishment. Skipping meals, fasting, or severely restricting carbohydrates can elevate cortisol and worsen DHEAS production (15).

Do:

• Eat breakfast within 1-2 hours of waking: This signals safety to your body and prevents a cortisol spike. Include protein, healthy fats, and complex carbohydrates.

• Include adequate carbohydrates: Aim for 100-150g per day minimum from whole food sources like sweet potatoes, oats, quinoa, and fruit. Low-carb diets can increase cortisol in women with adrenal dysfunction (16).

• Prioritise mineral-rich foods: Magnesium (leafy greens, nuts, seeds), potassium (bananas, avocados, potatoes), and sodium (Celtic sea salt, bone broth) support adrenal function and help regulate the stress response.

• Eat regular meals every 3-4 hours: Consistent meal timing prevents blood sugar crashes that trigger cortisol release.

• Focus on anti-inflammatory foods: Wild-caught fish, colourful vegetables, berries, olive oil, and herbs like turmeric can help reduce systemic inflammation associated with HPA-axis dysfunction (17).

Don't:

• Practice intermittent fasting or skip breakfast: Fasting is a metabolic stressor that activates the HPA axis. For Adrenal PCOS, it often does more harm than good.

• Follow very low-carb or ketogenic diets: Unless specifically recommended by a specialist familiar with your case, these approaches can increase cortisol and worsen symptoms.

• Rely on stimulants: Excessive caffeine (more than 1-2 cups per day) can overstimulate already sensitive adrenal glands.

Movement as Medicine

Exercise is essential for PCOS management, but the type and intensity matter enormously when dealing with Adrenal PCOS.

Switch from high-intensity to restorative movement:

Research shows that while moderate exercise improves PCOS symptoms, excessive high-intensity training can elevate cortisol and DHEAS in susceptible individuals (18). For Adrenal PCOS, less is often more.

Recommended approaches:

• Zone 2 cardio: Low-intensity, conversational-pace activities like brisk walking, easy cycling, or swimming for 30-45 minutes. This builds aerobic capacity without triggering a stress response.

• Yoga: Particularly restorative or yin yoga, which directly activates the parasympathetic nervous system (your "rest and digest" mode). Studies show yoga can reduce cortisol and improve hormonal balance in women with PCOS (19).

• Pilates or gentle strength training: Focus on controlled, mindful movement 2-3 times per week to maintain muscle mass without overtaxing your system.

• Walking in nature: Forest bathing or "Shinrin-Yoku" has been shown to lower cortisol, reduce anxiety, and improve mood (20).

For a comprehensive guide on choosing the right physical activities for your PCOS subtype, see our article on which sport to practice with PCOS.

Avoid or minimise:

• Daily HIIT or intense cardio: While HIIT has benefits for insulin-resistant PCOS, it can worsen Adrenal PCOS by adding more stress to an already dysregulated system.

• Fasted exercise: Training on an empty stomach amplifies cortisol release. Always eat a small meal or snack before workouts.

• Overtraining: Aim for no more than 4-5 moderate workouts per week, with at least 2 full rest days.

Listen to your body: if you feel more exhausted, anxious, or notice worsening symptoms after exercise, scale back intensity and duration.

Additional Recovery Tools

Prioritise sleep:

Sleep deprivation is one of the most powerful HPA-axis disruptors. Aim for 7-9 hours per night in a cool, dark room. Establish a consistent bedtime routine to signal your nervous system that it's safe to rest. Quality sleep is fundamental to hormonal balance, particularly when managing stress-driven PCOS.

Consider targeted supplementation:

Certain nutrients and botanicals can support your body's stress response and adrenal function. For a comprehensive overview of evidence-based supplementation for PCOS, see our science-backed guide to PCOS supplements.

• Magnesium bisglycinate (300-400mg before bed): Supports relaxation, sleep quality, and healthy cortisol rhythms (21). This highly bioavailable form is gentle on digestion and particularly effective for nervous system support. SOVA's Magnesium Bisglycinate provides 300mg per serving in this optimal form.
  

• Adaptogenic herbs: Rhodiola, saffron, and holy basil can help modulate the stress response and may reduce DHEAS in some women (22). Rhodiola in particular has been shown to improve stress resilience and reduce cortisol in multiple studies (23). SOVA's Serenity Booster combines rhodiola and saffron extract, two adaptogens with strong clinical evidence for stress management. For comprehensive nervous system support, the Serenity & Stress Relief Duo pairs these adaptogens with magnesium bisglycinate. Always consult a qualified practitioner before starting adaptogens, particularly if you have other health conditions or take medications.
  

• Vitamin C (500-1000mg daily): Supports adrenal gland function and may help lower cortisol (24).

• Omega-3 fatty acids (1-2g EPA/DHA daily): Reduces inflammation and supports hormonal balance.
  

Nervous system regulation practices:

• Deep breathing exercises (4-7-8 breathing, box breathing)
• Meditation or mindfulness practices
• Vagal nerve stimulation (humming, gargling, cold exposure)
• Therapy or somatic practices to address underlying trauma or chronic stress patterns

Anti-Stress Protocol: Dos and Don'ts

DO: ✓ Eat breakfast with protein, healthy fats, and carbs within 1-2 hours of waking ✓ Include 100-150g of complex carbohydrates daily ✓ Choose low-intensity movement: walking, yoga, Zone 2 cardio ✓ Prioritise 7-9 hours of sleep in a dark, cool room ✓ Practice daily stress-reduction techniques (meditation, breathwork) ✓ Eat regular meals every 3-4 hours to stabilise blood sugar ✓ Support adrenal function with magnesium, vitamin C, and omega-3s

DON'T: ✗ Practice intermittent fasting or skip breakfast ✗ Follow very low-carb or ketogenic diets long-term ✗ Do fasted HIIT or intense cardio more than 1-2x per week ✗ Overtrain without adequate recovery days ✗ Rely on caffeine to push through fatigue ✗ Ignore stress management in favour of "perfect" diet and exercise ✗ Restrict calories severely or follow extreme diets

Comparison Table: Adrenal PCOS vs. Insulin-Resistant PCOS

Finding the Right Balance

Adrenal PCOS is not a life sentence: it's a signal from your body that something in your stress-response system needs support. Unlike the standard PCOS advice that emphasises restriction and intensity, healing Adrenal PCOS requires you to slow down, nourish adequately, and prioritise rest.

The most important shift you can make is recognising that you cannot stress your way into healing a stress-based condition. The path forward involves giving your body the safety, consistency, and support it needs to recalibrate.

With the right approach: stable blood sugar, restorative movement, adequate sleep, and nervous system regulation, many women with Adrenal PCOS experience significant improvements in their symptoms. Acne clears, hair regrows, energy stabilises, and cycles become more regular.

You deserve personalised support that addresses your unique subtype. If standard PCOS protocols haven't worked for you, now you know why—and you have a new path forward.