From herbal hope to hormonal havoc: chronic ashwagandha use and HPA axis suppression.

Summary: This case report describes a 55-year-old postmenopausal woman who presented with Cushingoid features and progressive weight gain over a year. Evaluation revealed low basal cortisol levels and a suboptimal response to the ACTH stimulation test, indicative of adrenal insufficiency. Further investigation into her medication regimen uncovered her consistent use of approximately 950 mg of ashwagandha daily for over a year, prescribed by a local practitioner for symptomatic relief of bilateral knee osteoarthritis. A review of the existing literature suggested a potential cortisol-suppressing effect of ashwagandha, leading to the establishment of a causal link between the patient's symptoms and her consumption of the ashwagandha extract. She was advised to discontinue the alternative medication and commenced on hydrocortisone replacement, adjusted for her body surface area. A three-month follow-up indicated that her hypothalamic-pituitary-adrenal (HPA) axis suppression had not yet reversed, necessitating continued hydrocortisone supplementation and bimonthly monitoring of her basal and stimulated cortisol levels. This case report underscores the perils of unsupervised exposure to poorly understood compounds prevalent among the general public. It also highlights the role of online platforms and social media in promoting unverified practices and treatments with spurious claims of efficacy and safety, often in contrast to well-researched, modern treatment regimens. Through this case report, we would like to stress upon the importance of imposition of stringent regulations on social media and websites that disseminate unverified information. Furthermore, we emphasize that incentivizing and promoting health literacy among the general population is an urgent imperative. Learning points: Clinicians should be familiar with commonly used herbal remedies and their potential endocrine and systemic effects, particularly in the context of unexplained hormonal dysfunction. Cushingoid features and secondary adrenal insufficiency in the absence of exogenous steroid use should prompt clinicians to enquire specifically about herbal supplement intake, including dose, formulation, and duration. Both clinicians and the public should be aware that excessive doses and prolonged use of ashwagandha can lead to Cushingoid features and sustained suppression of the HPA axis. The widespread belief that 'natural' always equates to 'safe' needs to be actively challenged through public education campaigns and clinician-led counseling. Herbal products can cause deleterious health effects and are not inherently benign. There is a pressing need for health authorities to establish evidence-based guidelines for the safe use of ashwagandha and other commonly used herbal products, including daily dose limits and duration. International regulatory oversight and policies are essential to counter the growing misinformation around traditional and alternative medicines, especially on digital and social media platforms.