Ashwagandha and Hormonal Balance: How This Ancient Herb Reduces Cortisol, Modulates DHEA-S, and Supports Testosterone

Hormones orchestrate nearly every aspect of human physiology. They regulate metabolism, immune function, growth, reproduction, mood, cognition, sleep, and stress response. When hormonal balance deteriorates, particularly the delicate interplay between stress hormones and sex hormones, health consequences ripple through multiple systems.

Modern life disrupts hormonal equilibrium in ways our ancestors never faced. Chronic psychological stress from work deadlines, financial pressures, relationship demands, and information overload keeps stress hormones chronically elevated. Environmental toxins interfere with hormone production and signaling. Sleep deprivation disrupts circadian rhythms that govern hormone release. Sedentary lifestyles and processed diets compound the problem.

The result is a widespread epidemic of hormonal dysregulation manifesting as anxiety, depression, insomnia, fatigue, weight gain, sexual dysfunction, accelerated aging, and increased disease risk. Conventional medicine often addresses hormonal imbalances with synthetic hormone replacement or psychiatric medications, approaches that can provide relief but frequently produce side effects and fail to address root causes.

This is where a remarkable piece of research published in the journal Medicine offers compelling insights. The study examined how a standardized ashwagandha root extract affects stress, anxiety, and the hormonal systems that govern our response to stress and maintain vitality. The investigators measured not just subjective symptoms but objective biomarkers including cortisol, DHEA-S, and testosterone, providing a window into ashwagandha's mechanisms of action.

The findings reveal that ashwagandha works as a true adaptogen, modulating hormonal systems to restore balance rather than simply suppressing symptoms. The implications extend far beyond stress management to touch on fundamental aspects of health span, resilience, and quality of life.

Understanding the Hypothalamic-Pituitary-Adrenal Axis

To appreciate ashwagandha's effects, we need to understand the hypothalamic-pituitary-adrenal axis, commonly called the HPA axis. This integrated neuroendocrine system represents one of the body's primary mechanisms for responding to stress.

When you encounter a stressor (physical, psychological, or emotional), your hypothalamus releases corticotropin-releasing hormone. This signals your pituitary gland to secrete adrenocorticotropic hormone, which travels through the bloodstream to your adrenal glands. The adrenals then release cortisol and other hormones that mobilize your body's resources to handle the challenge.

In acute situations, this system works brilliantly. Cortisol mobilizes glucose for quick energy, suppresses non-essential functions like digestion and reproduction to conserve resources, enhances immune responses to injuries, sharpens focus and memory for threat assessment, and increases cardiovascular output to fuel action. The stress response evolved to help you survive genuine threats.

Problems emerge when stressors become chronic and the HPA axis remains persistently activated. Cortisol that should spike briefly and then return to baseline instead stays elevated day after day, week after week. This chronic activation disrupts the negative feedback loops that normally restore balance.

The consequences of HPA axis dysregulation and sustained cortisol elevation are profound. Metabolically, chronic cortisol promotes insulin resistance, visceral fat accumulation, elevated blood sugar, and dyslipidemia, creating a perfect storm for metabolic syndrome and type 2 diabetes. Immunologically, it suppresses adaptive immunity while promoting chronic low-grade inflammation, a combination that increases infection susceptibility while accelerating aging and disease processes.

Neurologically, sustained cortisol damages hippocampal neurons crucial for memory formation, impairs neuroplasticity, and contributes to mood disorders including anxiety and depression. Musculoskeletally, it promotes muscle protein breakdown, inhibits protein synthesis, and accelerates bone loss. Reproductively, chronic stress hormones suppress sex hormone production, impairing libido, fertility, and sexual function.

The hypothalamic-pituitary-gonadal axis, which governs sex hormone production, operates in constant communication with the HPA axis. When stress hormones chronically elevate, sex hormone production often declines, a phenomenon called the cortisol steal. The body essentially prioritizes survival (stress response) over reproduction (sex hormones), a trade-off that made sense for acute threats but becomes problematic with chronic stress.

Understanding this integrated hormonal network provides context for interpreting ashwagandha's effects across multiple hormone systems.

The Study Design: Comprehensive Hormonal Assessment

Researchers at healthcare centers in Bhopal and Pune, India, designed a 60-day randomized, double-blind, placebo-controlled trial examining ashwagandha's effects on stress, anxiety, and hormone production. The study enrolled 60 healthy adults aged 18 to 65 years who reported mild stress as measured by the Hamilton Anxiety Rating Scale.

Participants received either 240 mg daily of a standardized ashwagandha root extract (Shoden, standardized to contain at least 35% withanolide glycosides, delivering 84 mg of active compounds daily) or a matched placebo. This dose is notably lower than the 600 mg used in many previous studies, making the findings particularly relevant for understanding minimum effective doses.

The investigators employed both subjective and objective outcome measures, a crucial strength of the design. Subjective assessments included the Hamilton Anxiety Rating Scale, a clinician-administered tool assessing anxiety severity across 14 dimensions, and the Depression, Anxiety, and Stress Scale-21, a self-report measure capturing symptoms across these three domains.

The objective hormonal measurements provided biological validation of subjective improvements. Blood samples collected in the morning (when cortisol normally peaks) assessed serum cortisol, DHEA-S, and testosterone. Cortisol and DHEA-S were measured at baseline, day 30, and day 60, while testosterone was assessed at baseline and day 60.

This design allowed the researchers to determine whether anxiety improvements correlated with objective changes in stress hormones, providing mechanistic insights into how ashwagandha works. The inclusion of DHEA-S and testosterone measurements expanded understanding beyond cortisol to reveal effects on the broader hormonal milieu.

All 60 enrolled participants completed the full 60-day trial with no dropouts and no reported adverse events, a perfect retention and safety record that speaks to ashwagandha's tolerability. Compliance exceeded 90% as measured by capsule counts, ensuring participants actually received the intervention as designed.

Anxiety and Mood Results: Dramatic Improvements

The subjective mood measures revealed substantial improvements with ashwagandha supplementation compared to placebo.

Hamilton Anxiety Rating Scale scores decreased by 41% in the ashwagandha group over the 60-day period, compared to a 24% reduction in the placebo group. This difference reached statistical significance with a p-value of 0.040, indicating genuine treatment effects beyond placebo responses.

At baseline, both groups scored in the mild anxiety range. After 60 days, the ashwagandha group showed markedly lower anxiety levels that approached the normal range, while the placebo group remained in the mild anxiety category. The 41% reduction represents clinically meaningful improvement that would translate to noticeable changes in daily function, worry, physical tension, and quality of life.

The Depression, Anxiety, and Stress Scale-21 scores paralleled these findings. The ashwagandha group experienced a 30% reduction compared to just 10% in the placebo group. While this difference approached but did not quite reach statistical significance (p = 0.096), the consistent direction and magnitude of effect across both mood measures strengthens confidence in ashwagandha's anxiolytic properties.

These improvements occurred gradually and progressively over the 60 days rather than appearing suddenly, suggesting ashwagandha produces cumulative changes in underlying physiology rather than acute symptom suppression. Participants taking ashwagandha reported feeling calmer, less worried, better able to handle daily stressors, less physically tense, and more emotionally balanced.

Notably, these anxiety reductions occurred in healthy adults with mild stress, not in people diagnosed with clinical anxiety disorders. This suggests ashwagandha may benefit the large population of individuals experiencing subclinical stress and anxiety that doesn't meet diagnostic thresholds but significantly impairs quality of life.

Cortisol Results: Profound HPA Axis Modulation

The cortisol findings provided biological validation of the anxiety improvements while revealing how ashwagandha works at a mechanistic level.

Morning serum cortisol levels decreased by 23% in the ashwagandha group over 60 days, a statistically significant reduction (p < 0.001). In stark contrast, the placebo group showed essentially no change, with a negligible 0.5% increase. This between-group difference was highly significant (p < 0.001), indicating ashwagandha produced genuine cortisol-lowering effects.

The magnitude of this reduction deserves emphasis. A 23% decrease in cortisol represents a substantial shift in HPA axis activity. Cortisol levels in the ashwagandha group declined from an average of 14.15 mcg/dL at baseline to 10.84 mcg/dL at day 60, bringing levels into a more optimal range.

Gender-specific analyses revealed similar effects in both males and females. Women in the ashwagandha group experienced a 25% cortisol reduction compared to essentially no change in women taking placebo (p = 0.020 for between-group difference). Men showed a 22% reduction with ashwagandha versus a 1% increase with placebo (p = 0.011 for between-group difference).

The consistent cortisol-lowering effects across genders suggest ashwagandha's mechanisms operate similarly in males and females, at least regarding HPA axis modulation. This matters because some interventions show sex-specific effects due to interactions with sex hormones or sex-specific stress response patterns.

The cortisol reduction occurred progressively between baseline and day 30, then continued from day 30 to day 60, indicating sustained effects rather than rapid desensitization or tolerance development. This timeline suggests ashwagandha doesn't simply block cortisol production acutely but rather recalibrates HPA axis set points and responsiveness.

Lower cortisol would explain many of the symptomatic improvements participants experienced. Reduced cortisol means less activation of the amygdala (the brain's fear center), less disruption of prefrontal cortex function (the region governing rational thought and emotion regulation), better sleep architecture (cortisol should decline at night to facilitate sleep), improved insulin sensitivity, reduced muscle protein breakdown, better immune function, and decreased systemic inflammation.

The cortisol findings suggest ashwagandha helps restore appropriate stress responses rather than eliminating stress reactivity entirely. The goal isn't zero cortisol (which would be harmful) but rather cortisol that rises appropriately to actual demands and then efficiently returns to baseline. Ashwagandha appears to enhance this regulatory capacity.

DHEA-S Results: A Surprising Finding

The DHEA-S results revealed an unexpected aspect of ashwagandha's hormonal effects that challenges simplistic interpretations of the research.

DHEA-S levels decreased by 8% in the ashwagandha group over 60 days, a statistically significant change (p = 0.007). The placebo group showed a small 2.5% increase that was not statistically significant. The between-group difference was significant (p = 0.004), confirming ashwagandha produced genuine DHEA-S lowering.

This finding surprises because DHEA-S is often considered a beneficial hormone associated with longevity, vitality, and health. Higher DHEA-S levels generally correlate with better health outcomes in population studies. Why would ashwagandha lower a hormone typically viewed as protective?

The answer lies in understanding DHEA-S in the context of stress physiology. While high DHEA-S generally indicates health in unstressed individuals, elevated DHEA-S can also reflect HPA axis activation and stress response, similar to cortisol. Both cortisol and DHEA are produced in the adrenal cortex, though in different layers, and both increase during stress exposure.

Studies of acute stress consistently show DHEA-S rising alongside cortisol. Higher DHEA-S appears in people with post-traumatic stress disorder and correlates with cigarette smoking and alcohol consumption, both stress-related behaviors. In this context, elevated DHEA-S may indicate chronic HPA axis activation rather than optimal health.

The coordinated reduction in both cortisol and DHEA-S with ashwagandha supplementation suggests the herb modulates overall HPA axis activity rather than selectively affecting one hormone. Ashwagandha appears to calm an overactive stress response system, reducing production of multiple adrenal hormones that rise during chronic stress.

This interpretation fits with ashwagandha's traditional classification as an adaptogen. Adaptogens help organisms adapt to stress by normalizing physiological processes rather than simply stimulating or suppressing them. In a chronically stressed individual with elevated cortisol and DHEA-S reflecting HPA axis overactivation, reducing both hormones toward normal ranges represents restoration of balance rather than harmful suppression.

Gender-specific analyses showed DHEA-S reduction trends in both males (8% decrease) and females (9% decrease), though these narrowly missed statistical significance within each gender group individually. The pooled analysis achieved significance, indicating genuine effects that individual gender subgroups were slightly underpowered to detect.

The DHEA-S findings underscore an important principle: optimal hormone levels depend on context. Interventions should be evaluated based on whether they move dysregulated systems toward balance, not based on whether they universally increase or decrease any particular hormone.

Testosterone Results: Gender-Specific Effects

The testosterone findings revealed intriguing gender differences in ashwagandha's hormonal effects.

In the ashwagandha group overall, testosterone increased by 11% over 60 days, a statistically significant change within the group (p = 0.043). The placebo group showed essentially no change (0.1% increase). However, the between-group difference did not quite reach statistical significance (p = 0.150), possibly due to sample size limitations and gender-specific effects.

Gender-stratified analyses revealed why the overall comparison narrowly missed significance. In men, testosterone increased by 11.4% with ashwagandha supplementation, rising from an average of 474 ng/dL at baseline to 528 ng/dL at day 60. This compared to essentially no change (0.1% increase) in men taking placebo. However, the between-group difference did not reach statistical significance (p = 0.158), likely due to the modest sample size of 37 males.

In women, testosterone showed no significant change in either group. The ashwagandha group experienced a negligible 0.2% decrease, while the placebo group showed a 1.3% decrease. This makes biological sense given that women have much lower baseline testosterone levels than men, and the mechanisms driving testosterone production differ substantially between sexes.

The male-specific testosterone increase of 11.4% (approximately 54 ng/dL) carries potential clinical significance. Testosterone declines by approximately 1-2% annually after age 30 in men, translating to roughly 110 ng/dL per decade. The 54 ng/dL increase observed after just 60 days of ashwagandha supplementation represents approximately five years worth of age-related decline.

While 54 ng/dL may not transform a man with low testosterone into the high-normal range, it could make meaningful differences in energy, mood, libido, muscle maintenance, cognitive function, and motivation, particularly in men whose levels have declined from their youthful peaks.

The testosterone findings align with other research showing ashwagandha influences the hypothalamic-pituitary-gonadal axis. Several mechanisms might explain the effect. Reduced cortisol could alleviate the cortisol steal, allowing more precursor molecules to flow toward testosterone synthesis. Direct effects of withanolides on testicular Leydig cells might enhance testosterone production. Reduced oxidative stress and inflammation could protect Leydig cells from damage that impairs steroidogenesis.

Importantly, the testosterone increase occurred naturally through enhanced endogenous production rather than through exogenous hormone administration. This preserves normal feedback regulation and avoids the suppression of natural production that occurs with testosterone replacement therapy.

Mechanisms of Action: How Ashwagandha Works

While this study did not directly investigate mechanisms, the pattern of hormonal changes illuminates how ashwagandha produces its therapeutic effects.

The coordinated reduction in cortisol and DHEA-S points to modulation of HPA axis activity as a primary mechanism. Several potential points of intervention exist. Ashwagandha might enhance negative feedback sensitivity, meaning the hypothalamus and pituitary respond more readily to cortisol signals to shut down further hormone release. This would prevent excessive or prolonged HPA axis activation in response to stressors.

Withanolides could influence glucocorticoid receptor sensitivity or number in brain regions that regulate the HPA axis. Altered receptor dynamics would change how the brain perceives and responds to circulating cortisol levels. The compounds might also directly affect adrenal steroidogenesis, the enzymatic pathways that synthesize cortisol and other adrenal hormones.

At the cellular level, ashwagandha's constituents possess direct antioxidant and anti-inflammatory properties. Oxidative stress and inflammation activate the HPA axis and perpetuate stress responses. By reducing these signals, ashwagandha could indirectly calm HPA axis activity.

The herb also influences neurotransmitter systems involved in stress and anxiety. Animal studies demonstrate ashwagandha enhances GABA (gamma-aminobutyric acid) activity, the brain's primary inhibitory neurotransmitter. GABA receptors mediate anxiolytic effects of benzodiazepines, and natural enhancement of GABA signaling would reduce anxiety without the side effects and dependency risks of pharmaceutical GABAergic drugs.

Ashwagandha also affects serotonin systems, another key regulator of mood, anxiety, and stress responses. The combination of enhanced GABAergic and serotonergic activity would synergistically reduce anxiety while improving mood and stress resilience.

The testosterone increase in men likely results from multiple converging mechanisms. Reduced cortisol alleviates competitive inhibition of testosterone synthesis. Lower systemic inflammation protects testicular function. Improved sleep quality (documented in other ashwagandha studies) supports nocturnal testosterone production. Withanolides may directly stimulate testicular Leydig cells or enhance pituitary secretion of luteinizing hormone, which signals testosterone production.

These mechanisms don't operate in isolation but interact synergistically. Reduced cortisol improves sleep, which supports testosterone production and reduces inflammatory signaling, which further calms HPA axis activation. The resulting positive feedback loops amplify benefits beyond what any single mechanism could achieve alone.

Broader Health Implications Beyond Stress Management

While the study focused on stress and anxiety, the hormonal changes documented carry implications across multiple health domains.

Metabolic health stands to benefit substantially from cortisol reduction and testosterone support. Chronically elevated cortisol promotes insulin resistance, one of the central features of metabolic syndrome. It stimulates hepatic gluconeogenesis, increasing fasting blood sugar. It redistributes fat toward visceral (abdominal) depots, the most metabolically harmful fat storage pattern. Reducing cortisol addresses all these metabolic disturbances.

The modest testosterone increase in men would further support metabolic health. Testosterone enhances insulin sensitivity, promotes lean muscle mass, and supports healthy fat metabolism. Low testosterone correlates strongly with metabolic syndrome, type 2 diabetes, and cardiovascular disease in men.

Cardiovascular health connects intimately to stress hormones. Chronic cortisol elevation promotes hypertension through multiple mechanisms including increased vascular reactivity, sodium retention, and increased production of angiotensin II. It accelerates atherosclerosis by promoting endothelial dysfunction, increasing oxidative stress, and driving inflammatory processes in arterial walls.

Cognitive function depends heavily on appropriate cortisol levels. Acute cortisol enhances memory consolidation and sharpens focus, but chronic elevation damages hippocampal neurons, impairs neuroplasticity, disrupts prefrontal cortex function, and accelerates cognitive decline. The cortisol reduction observed with ashwagandha supplementation could protect cognitive function and potentially reduce dementia risk over the long term.

Immune function requires cortisol balance. While acute cortisol appropriately suppresses inflammation after injuries, chronic elevation impairs T cell function, reduces natural killer cell activity, decreases antibody production, and increases susceptibility to infections. Simultaneously, it promotes chronic low-grade inflammation through complex mechanisms. Restoring appropriate cortisol levels would optimize immune surveillance while reducing inflammatory disease risk.

Body composition reflects the balance between cortisol and testosterone. Elevated cortisol promotes muscle protein breakdown, inhibits protein synthesis, and drives fat accumulation, particularly visceral fat. Testosterone exerts opposite effects: promoting muscle protein synthesis, supporting muscle mass, and facilitating fat oxidation. The hormonal shift with ashwagandha supplementation (reduced cortisol, increased testosterone in men) would favor improved body composition with maintained or increased lean mass and reduced fat mass.

Sexual function and fertility depend on appropriate stress and sex hormone balance. Chronic stress and elevated cortisol suppress libido, impair erectile function in men, disrupt menstrual cycles in women, and reduce fertility in both sexes. The combination of reduced cortisol and increased testosterone would support sexual function through multiple mechanisms.

Bone health represents another domain affected by the cortisol-testosterone balance. Cortisol accelerates bone resorption and inhibits bone formation, directly contributing to osteoporosis. Testosterone supports bone formation and maintenance. The hormonal changes with ashwagandha would favor bone health, particularly relevant for aging populations at risk for osteoporotic fractures.

Clinical Context: Who Benefits Most?

Understanding the study population helps determine who might benefit most from ashwagandha supplementation for hormonal balance.

The study enrolled healthy adults with mild stress and anxiety, not people with diagnosed mental health conditions or severe hormonal disorders. This represents a large population experiencing subclinical symptoms that impair quality of life but don't meet diagnostic thresholds for medical treatment.

Many people find themselves in this middle ground: stressed enough to feel anxious, tired, and unable to perform at their best, but not severely impaired enough to warrant pharmaceutical intervention. This population often receives minimal support from conventional medicine beyond advice to manage stress better, a recommendation that proves difficult to implement without practical tools.

Individuals with demonstrable signs of HPA axis dysregulation would likely benefit significantly. Indicators include sustained high perceived stress, anxiety symptoms, difficulty recovering from stress, sleep problems (particularly trouble falling asleep or early morning awakening), afternoon fatigue, difficulty losing weight despite appropriate diet and exercise, frequent illness, slow recovery from exercise or injury, loss of libido, and mood instability.

Men experiencing age-related testosterone decline could particularly benefit from ashwagandha's dual effects on reducing cortisol while supporting testosterone. The combination addresses both the elevated cortisol common in stressed middle-aged men and the declining testosterone that accompanies aging.

Women experiencing stress-related hormonal symptoms including irregular cycles, premenstrual mood changes, low libido, or menopausal symptoms complicated by stress might benefit from cortisol reduction even without the testosterone effects seen in men. The study showed women experienced similar cortisol reductions to men, suggesting equivalent stress-modulating benefits.

Athletes and physically active individuals represent another population that could benefit substantially. Intense training elevates cortisol, and inadequate recovery keeps it elevated chronically. This overtraining state impairs performance, increases injury risk, and compromises health. Ashwagandha's cortisol-lowering and testosterone-supporting effects address the hormonal profile of overtraining while supporting recovery and adaptation.

People experiencing life transitions or periods of elevated stress (career changes, relationship challenges, caregiving responsibilities, health problems) might use ashwagandha as temporary support to maintain hormonal balance during demanding periods.

Those seeking to optimize health span and longevity could view ashwagandha as preventive medicine. By maintaining more favorable hormonal balance throughout midlife and beyond, it may help prevent or delay the numerous chronic diseases associated with HPA axis dysregulation and sex hormone decline.

Practical Application: Dosing and Implementation

The study's findings provide clear guidance for practical application of ashwagandha for hormonal balance.

The dose used was notably modest: 240 mg daily of a standardized extract containing at least 35% withanolide glycosides, delivering 84 mg of active compounds. This lower dose produced significant benefits, suggesting individuals need not take the 600 mg doses used in many other studies to achieve meaningful hormonal effects.

Starting with 240-300 mg daily allows assessment of individual response while minimizing any adjustment period some people experience when beginning adaptogenic herbs. The dose can be increased to 600 mg daily if benefits seem incomplete or if stress levels are particularly high.

Timing matters for optimization. The study administered ashwagandha once daily after dinner. This evening timing makes sense given cortisol's circadian rhythm. Cortisol should naturally decline in the evening to facilitate sleep, but many stressed individuals maintain elevated evening cortisol that disrupts sleep onset. Evening ashwagandha supplementation may support the natural circadian decline in cortisol.

However, some practitioners recommend split dosing (half in morning, half in evening) to maintain more stable blood levels of active compounds throughout the day. Either approach can be effective; individual experimentation helps determine which timing produces optimal results.

Consistency proves crucial. The study's benefits emerged progressively over 60 days rather than appearing immediately. Participants took ashwagandha daily throughout this period with excellent compliance. Sporadic or occasional use likely produces minimal benefits. Viewing ashwagandha as a daily foundational supplement rather than an as-needed remedy aligns with how adaptogens work.

Fathom Nutrition's Ashwagandha provides research-grade KSM-66 extract standardized to contain at least 5% withanolides, matching the quality standards used in clinical research. Each serving delivers the dose range shown effective in human studies, providing confidence in achieving the documented hormonal benefits.

Quality matters enormously with botanical supplements. Ashwagandha products vary dramatically in active compound content, purity, and effectiveness. Look for products using standardized extracts from reputable manufacturers, third-party testing for purity and potency, clear labeling of withanolide content (typically 5% or higher), and preferably root-only extracts rather than whole plant powder.

Integration with other interventions amplifies benefits. Ashwagandha works synergistically with lifestyle practices that support hormonal balance. Adequate sleep (7-9 hours nightly) is fundamental; cortisol dysregulation and sleep disruption form vicious cycles that ashwagandha helps break. Regular exercise provides stress relief and supports healthy testosterone production, particularly resistance training in men. Mindfulness practices like meditation directly influence HPA axis activity and amplify ashwagandha's stress-reducing effects.

Nutritional foundations matter. Adequate protein intake supports testosterone production and prevents muscle loss that cortisol promotes. Sufficient micronutrients, particularly zinc, magnesium, and vitamin D, support steroid hormone synthesis. Fathom Nutrition's comprehensive supplement line addresses common nutritional gaps that may limit hormonal optimization.

For sleep challenges related to stress and cortisol dysregulation, Fathom Nutrition's Sleep Formula combines ashwagandha with other evidence-based sleep-supporting nutrients for comprehensive nighttime recovery support.

Timeline expectations should be realistic. Participants in this study noticed improvements by 30 days, with continued enhancement through day 60. Planning for at least 2 months of consistent supplementation before evaluating full effectiveness aligns with the research.

Monitoring response helps optimize usage. Track subjective measures like stress levels, anxiety symptoms, sleep quality, energy, mood, motivation, and physical well-being. If possible, measure objective markers. Cortisol can be assessed through serum tests, salivary measurements (which capture free cortisol), or 24-hour urine collections (which provide integrated daily production). Testosterone measurements in men provide another objective marker, ideally assessed as free testosterone or calculated bioavailable testosterone rather than just total testosterone.

Safety, Tolerability, and Contraindications

The study's perfect safety record deserves emphasis. All 60 participants completed the full 60 days with zero reported adverse events. Hematological measures including complete blood count and lipid profile showed no concerning changes. Compliance exceeded 90%, indicating participants tolerated ashwagandha well enough to take it consistently.

This excellent safety profile aligns with extensive traditional use spanning thousands of years and numerous modern clinical trials. Ashwagandha consistently demonstrates favorable safety when used appropriately.

Side effects, when they occur, tend to be mild and transient. Some people experience mild gastrointestinal upset when first beginning supplementation, typically resolving within days to a week. Taking ashwagandha with food minimizes this concern. Rarely, individuals report feeling overstimulated or experiencing vivid dreams, in which case reducing dose or shifting timing earlier in the day often resolves the issue.

Certain populations should exercise caution or avoid ashwagandha. Pregnant women should not use ashwagandha due to traditional concerns about uterine stimulation, though rigorous safety data in pregnancy is limited. Lactating women should consult healthcare providers, as transfer into breast milk and effects on nursing infants have not been adequately studied.

Individuals with autoimmune conditions should discuss ashwagandha use with knowledgeable practitioners. While the immunomodulatory effects may theoretically benefit some autoimmune conditions, concerns exist about potentially stimulating immune activity in conditions where immune suppression is therapeutic. Clinical experience suggests many people with autoimmune conditions tolerate and benefit from ashwagandha, but individualized assessment is warranted.

Those taking thyroid medications should monitor thyroid function, as ashwagandha can modestly increase thyroid hormone levels in some individuals. This isn't necessarily problematic and might even be beneficial, but thyroid medication doses may require adjustment. Regular monitoring ensures thyroid hormones remain in optimal ranges.

People taking medications for anxiety, depression, or insomnia should be aware of potential additive effects. Ashwagandha enhances GABAergic and serotonergic activity, which could theoretically interact with medications affecting these neurotransmitter systems. Most people tolerate the combination well, but monitoring for excessive sedation or other unexpected effects makes sense when beginning ashwagandha alongside psychotropic medications.

Individuals taking diabetes medications should monitor blood glucose, as improved insulin sensitivity with ashwagandha supplementation could necessitate medication adjustments to avoid hypoglycemia.

Anyone with concerns about interactions with specific medications should consult with healthcare providers knowledgeable about botanical medicine and potential interactions.

Study Limitations and Future Research Directions

Like all research, this study has limitations that suggest directions for future investigation.

The 60-day duration captured meaningful changes but leaves questions about long-term effects. Do hormonal benefits continue beyond 60 days, plateau, or potentially diminish with extended use? How long do benefits persist after discontinuing supplementation? Studies extending to 6-12 months would address these questions.

The sample size of 60 participants, while adequate for detecting the observed effects, limited ability to explore subgroup differences. Larger studies could examine which individuals respond most dramatically based on age, baseline hormone levels, stress severity, body composition, lifestyle factors, or genetic variations.

The study population consisted entirely of Indian adults. While hormonal physiology operates similarly across populations, cultural factors, dietary patterns, genetic variations, and environmental exposures could influence response magnitude. Replication in diverse populations would strengthen confidence in generalizability.

The single dose studied (240 mg daily) proved effective but doesn't define the optimal dose. Dose-ranging studies comparing 120 mg, 240 mg, 480 mg, and 600 mg daily would better characterize dose-response relationships and help determine whether higher doses provide incrementally greater benefits or simply reach a plateau.

The study measured cortisol, DHEA-S, and testosterone but not other hormones influenced by stress and the HPA axis. Measuring pregnenolone, progesterone, estrogens, growth hormone, IGF-1, thyroid hormones, and additional markers would provide a more complete picture of ashwagandha's hormonal effects.

The mechanisms investigation remained inferential based on observed effects. Future studies incorporating more detailed assessments (gene expression analysis, receptor binding studies, imaging of HPA axis structures, detailed circadian hormone profiling) would illuminate precisely how ashwagandha produces its effects.

The relationship between hormonal changes and symptom improvements could be explored more rigorously. Did individuals with larger cortisol reductions experience greater anxiety improvements? Do testosterone increases correlate with specific symptom changes? Statistical analyses examining these correlations would strengthen mechanistic understanding.

The study enrolled people with mild stress. Investigation in populations with diagnosed anxiety disorders, major depression, PTSD, or clinically significant hormonal imbalances would determine whether ashwagandha benefits extend to more severe conditions or primarily supports subclinical symptoms.

Combination studies testing ashwagandha alongside other interventions (exercise programs, other botanical medicines, psychological therapies, dietary modifications) would determine whether combined approaches produce synergistic benefits exceeding individual interventions.

Comparative Context: Ashwagandha Versus Other Interventions

Placing ashwagandha in context alongside other approaches to hormonal balance and stress management helps clarify its unique position.

Pharmaceutical anxiolytics like benzodiazepines provide rapid symptom relief but don't address underlying hormonal dysregulation and carry significant risks including cognitive impairment, dependency, tolerance, withdrawal symptoms, and fall/accident risk. SSRIs and SNRIs require weeks to take effect, often produce side effects including sexual dysfunction and emotional blunting, and don't directly address cortisol dysregulation.

Lifestyle interventions including exercise, meditation, adequate sleep, and stress management techniques effectively support hormonal balance and should form the foundation of any comprehensive approach. However, these require sustained effort and behavior change that many people struggle to implement consistently. Ashwagandha offers a complementary tool that supports hormonal balance while people work on these foundational practices.

Testosterone replacement therapy in men with clinically low testosterone produces dramatic increases in testosterone levels but suppresses natural production, requires ongoing monitoring, carries risks including cardiovascular concerns and prostate issues, and doesn't address elevated cortisol or the root causes of hormonal imbalance. Ashwagandha's modest testosterone support works through enhanced endogenous production, preserving feedback regulation and avoiding the risks of exogenous hormone administration.

Phosphatidylserine, another supplement studied for cortisol reduction, shows effects similar in magnitude to ashwagandha but lacks the additional benefits on testosterone and anxiety. Rhodiola rosea, a fellow adaptogen, demonstrates stress-reducing properties but appears more stimulating in its effects and may not offer the sleep benefits and profound anxiolytic effects of ashwagandha.

Ashwagandha's unique profile combines significant cortisol reduction, modulation of DHEA-S suggesting broad HPA axis effects, testosterone support in men, anxiolytic effects comparable to some pharmaceutical agents, and excellent safety and tolerability. This multifaceted benefit profile distinguished from interventions that target single pathways or produce benefits alongside significant drawbacks.

The Cortisol-Testosterone Balance: A Key to Understanding Benefits

The coordinated effects on cortisol and testosterone deserve deeper examination because their balance profoundly influences health, vitality, and quality of life.

Cortisol and testosterone exist in a dynamic relationship, often described as antagonistic or competing. At a biochemical level, both hormones derive from cholesterol through a series of enzymatic conversions. When the body prioritizes cortisol production during chronic stress, the flow of precursor molecules toward testosterone synthesis can diminish, a phenomenon called pregnenolone steal or cortisol steal.

Beyond competition for precursors, cortisol directly inhibits testosterone production through effects on the hypothalamic-pituitary-gonadal axis. Elevated cortisol suppresses gonadotropin-releasing hormone from the hypothalamus, which reduces luteinizing hormone release from the pituitary, which then decreases testosterone synthesis in the testes. Cortisol also directly inhibits testicular Leydig cells that produce testosterone.

The consequences of unfavorable cortisol-testosterone ratios extend across multiple domains. Metabolically, high cortisol promotes insulin resistance while low testosterone impairs insulin sensitivity, creating a double metabolic insult. Cortisol drives visceral fat accumulation while testosterone promotes lean muscle mass; their imbalance accelerates sarcopenic obesity, the combination of muscle loss and fat gain particularly harmful in aging.

Cognitively, elevated cortisol impairs memory and executive function while testosterone supports cognitive performance, particularly spatial reasoning and processing speed. The combination of high cortisol and declining testosterone contributes to the cognitive changes many people experience with chronic stress and aging.

Emotionally, cortisol elevation increases anxiety and depression risk while testosterone supports mood, motivation, and emotional resilience. Low testosterone correlates strongly with depression in men, and the combination with elevated cortisol creates a particularly unfavorable emotional state.

Sexually, cortisol suppresses libido and function while testosterone drives sexual interest and performance in both sexes (though women require much lower absolute levels). The stress-related sexual dysfunction many people experience reflects this hormonal interplay.

In terms of vitality and life engagement, cortisol promotes fatigue and exhaustion while testosterone supports energy, drive, competitiveness, and goal-directed behavior. The combination of elevated cortisol and low testosterone manifests as the apathetic fatigue characteristic of burnout.

Ashwagandha's ability to simultaneously reduce cortisol while supporting testosterone creates a more favorable hormonal milieu across all these domains. Rather than addressing symptoms in isolation, it shifts fundamental hormonal drivers in beneficial directions.

Individual Variation and Response Optimization

While the study showed average improvements, individual responses undoubtedly varied. Understanding factors that influence response helps optimize ashwagandha use.

Baseline cortisol levels likely predict response magnitude. Individuals with markedly elevated cortisol probably experience more dramatic reductions and symptom improvements than those with cortisol already in the normal range. This suggests ashwagandha works as a true adaptogen, normalizing dysregulated systems rather than simply suppressing hormone production universally.

Age influences hormonal baselines and response patterns. Younger adults with more robust hormonal function might experience different effects than middle-aged or older individuals with age-related changes in hormone production and regulation. The testosterone increase observed in men might prove more pronounced in those experiencing age-related decline.

Lifestyle context matters enormously. Someone practicing multiple stress management techniques (regular exercise, meditation, adequate sleep, strong social connections) while taking ashwagandha likely experiences synergistic benefits exceeding either approach alone. Conversely, someone continuing high-stress lifestyle patterns while adding only ashwagandha might see more modest improvements.

Genetic variations in hormone metabolism, receptor sensitivity, and enzyme activity influence both baseline hormonal status and response to interventions. Polymorphisms in genes encoding cortisol receptors, cortisol-metabolizing enzymes (like 11-beta hydroxysteroid dehydrogenase), and testosterone-related genes could all affect ashwagandha response. As genetic testing becomes more accessible, personalized predictions of response likelihood may become feasible.

Body composition and metabolic health interact with hormonal balance. Excess body fat, particularly visceral fat, promotes inflammation and insulin resistance that dysregulate hormone production. Ashwagandha might work more effectively in metabolically healthy individuals or might require longer duration in those with metabolic syndrome to produce equivalent benefits.

Concurrent medications or supplements could interact with ashwagandha, enhancing or diminishing effects. While the study excluded people taking psychotropic medications or other herbs, real-world users often combine interventions. Some combinations might prove synergistic (for example, ashwagandha plus vitamin D plus magnesium for comprehensive hormonal support), while others might be redundant.

The gut microbiome increasingly appears crucial for metabolizing botanical compounds. Withanolides undergo metabolism by gut bacteria before absorption, and individual differences in microbiome composition might affect how much active compound reaches the bloodstream and tissues. This suggests that optimizing gut health through fermented foods, adequate fiber, and potentially probiotic supplementation might enhance ashwagandha effectiveness.

Stress type and chronicity influence response. Acute high-intensity stress differs from chronic low-level stress, and responses to each might vary. Someone experiencing a discrete stressful period (major life transition, intense work project) might respond differently than someone with years of accumulated stress.

Economic and Accessibility Considerations

The practical reality of supplement use includes economic factors and accessibility that influence whether research findings translate to real-world benefits.

Ashwagandha offers favorable economics compared to many interventions. Quality standardized extracts typically cost $15-35 monthly, far less than pharmaceutical anxiolytics or testosterone replacement therapy. The absence of patent protection (traditional herbs cannot be patented) allows multiple manufacturers to produce quality products, maintaining competitive pricing.

Insurance rarely covers supplements, making out-of-pocket costs a consideration. However, the potential to avoid or reduce need for prescription medications, medical visits, and management of medication side effects could offset supplementation costs. Preventing stress-related health problems through early intervention with ashwagandha might prove far more economical than treating developed conditions later.

Accessibility extends beyond economics to availability and knowledge. Quality ashwagandha products are increasingly available through health food stores, online retailers, and companies like Fathom Nutrition that ship nationwide. However, many people experiencing stress and hormonal symptoms remain unaware of ashwagandha or don't understand how to use it effectively.

Healthcare provider knowledge varies widely. While some practitioners enthusiastically recommend ashwagandha based on research evidence, others remain unfamiliar with the literature or skeptical of botanical interventions. This knowledge gap means many patients who could benefit never receive appropriate guidance.

Cultural acceptance influences use patterns. In India, where the study was conducted and where Ayurveda maintains widespread respect, acceptance of ashwagandha comes naturally. In Western countries, some individuals embrace botanical medicine enthusiastically while others prefer pharmaceutical approaches exclusively. Bridging this gap requires continued research demonstrating efficacy through rigorous methods Western medicine respects.

Quality assurance represents another accessibility challenge. The supplement industry includes both reputable manufacturers using rigorous quality control and less scrupulous producers offering substandard products. Consumers need guidance identifying quality products, understanding what standardization means, recognizing the importance of third-party testing, and interpreting supplement labels.

The Dose Question: Lower May Be Effective

The study's use of just 240 mg daily of ashwagandha extract carrying implications for practical recommendations. Most previous research used 600 mg daily, twice the dose in this study, yet this lower dose produced meaningful benefits.

The cost savings of lower effective doses prove substantial. If 240 mg daily works as well as 600 mg for most people, supplementation costs drop proportionally. More importantly, some individuals hesitate to take multiple large capsules daily; lower effective doses increase adherence likelihood.

The findings suggest a dose-response curve where benefits increase with dose up to a point, then plateau. The 240 mg dose may sit near the lower end of the therapeutic range for most people, providing substantial benefits while leaving room for dose increases if response seems incomplete.

Individual factors likely influence optimal dosing. Someone with severe stress and markedly elevated cortisol might benefit from 600 mg daily while someone with mild stress achieves sufficient benefits with 240-300 mg. Body weight could influence optimal dose, with larger individuals potentially requiring higher amounts to achieve equivalent tissue concentrations.

The standardization matters as much as total dose. This study used an extract standardized to at least 35% withanolide glycosides, meaning each 240 mg capsule provided 84 mg of active compounds. Other extracts standardized to 5% withanolides would require approximately 1,700 mg to deliver equivalent active compounds. Comparing products requires looking at active compound content, not just total extract weight.

Starting with lower doses (240-300 mg daily) and increasing if needed provides a rational approach. This allows assessment of individual response and tolerance while minimizing costs. If benefits seem incomplete after 30-60 days at the lower dose, increasing to 600 mg daily provides additional support.

The time course of benefits also influences dosing strategy. Since improvements occurred progressively over 60 days rather than appearing immediately, patience proves essential. Increasing dose prematurely before the full effects of a lower dose manifest could lead to unnecessary supplementation at higher levels.

Gender Differences: Beyond Testosterone

While the testosterone findings highlighted clear gender differences, the cortisol and anxiety results revealed more similarities than differences between males and females.

Both men and women experienced approximately 23-25% cortisol reductions, suggesting ashwagandha modulates HPA axis activity similarly across sexes. This makes biological sense given that the fundamental architecture and regulation of the HPA axis is conserved between males and females, despite some differences in baseline activity levels and reactivity patterns.

Both sexes showed similar DHEA-S reductions (8-9%), again suggesting comparable effects on adrenal steroid production. The adrenal cortex functions similarly in males and females, producing both cortisol and DHEA regardless of sex.

Anxiety improvements appeared similar across genders, with both experiencing substantial reductions in Hamilton Anxiety Rating Scale scores. While the study didn't report gender-stratified anxiety results separately, the similar cortisol effects suggest comparable anxiolytic benefits.

The testosterone divergence makes perfect sense given dramatically different baseline levels and regulatory mechanisms. Men produce 15-20 times more testosterone than women, primarily from testicular Leydig cells under control of the hypothalamic-pituitary-gonadal axis. Women produce small amounts from ovaries and adrenal glands through different pathways.

Despite lack of testosterone increase in women, ashwagandha still offers substantial benefits through cortisol reduction, anxiety improvement, and potentially effects on other hormones not measured in this study. Women experiencing stress-related symptoms, sleep problems, mood issues, or concerns about accelerated aging could benefit significantly from ashwagandha's cortisol-lowering and anxiolytic effects.

For women specifically concerned about hormonal balance, ashwagandha's effects on cortisol could indirectly support female sex hormone production. Elevated cortisol disrupts normal menstrual cycles, contributes to irregular periods and anovulation, worsens premenstrual symptoms, and complicates perimenopause and menopause. Normalizing cortisol helps restore more regular hormonal rhythms.

Some women might experience modest changes in estrogen or progesterone with ashwagandha, though this study didn't measure these hormones. Future research examining ashwagandha's effects on female sex hormones across the menstrual cycle and in different life stages (reproductive years, perimenopause, postmenopause) would clarify gender-specific applications.

Integration With Comprehensive Wellness Strategies

Ashwagandha works best not as an isolated intervention but as one component of comprehensive wellness strategies addressing multiple aspects of hormonal health and stress resilience.

Sleep optimization represents perhaps the most crucial complementary intervention. Sleep deprivation elevates cortisol, impairs testosterone production, disrupts HPA axis regulation, and exacerbates anxiety. Even with ashwagandha supplementation, chronic sleep deprivation undermines hormonal balance. Prioritizing 7-9 hours nightly, maintaining consistent sleep schedules, optimizing sleep environment, and managing factors disrupting sleep creates a foundation for ashwagandha's benefits.

Fathom Nutrition's Sleep Formula provides comprehensive nighttime support, combining ashwagandha with other evidence-based sleep-promoting nutrients. The synergy between ashwagandha's stress-reducing effects and targeted sleep support may produce superior results compared to either approach alone.

Exercise provides powerful stress management and hormonal benefits. Resistance training supports testosterone production in men and improves body composition in both sexes. Cardiovascular exercise enhances cardiovascular health and provides psychological stress relief. Movement practices like yoga combine physical activity with mindfulness for comprehensive benefits. The combination of regular exercise and ashwagandha supplementation likely produces synergistic improvements in stress resilience and hormonal balance.

Nutrition fundamentally supports hormone production and regulation. Adequate protein provides amino acids for neurotransmitter synthesis and supports muscle maintenance against cortisol's catabolic effects. Healthy fats supply cholesterol and essential fatty acids needed for steroid hormone synthesis. Micronutrients including zinc, magnesium, vitamin D, B vitamins, and others serve as cofactors in enzymatic pathways producing and metabolizing hormones.

Fathom Nutrition's comprehensive supplement line addresses common nutritional gaps that may limit hormonal optimization. Combining foundational nutritional support with targeted interventions like ashwagandha creates conditions for optimal hormone production and function.

Stress management techniques including meditation, breathwork, progressive muscle relaxation, and cognitive behavioral approaches directly influence HPA axis activity. These practices strengthen prefrontal cortex regulation of limbic stress responses, enhance vagal tone supporting parasympathetic activity, and build resilience to stressors. The combination of these mental training practices with ashwagandha's biological support creates comprehensive stress management.

Social connection and meaningful relationships buffer against stress through multiple mechanisms. Strong social support reduces perceived stress, provides practical assistance during challenges, offers emotional validation, and activates neural circuits that oppose stress responses. While ashwagandha can't replace human connection, it may help people feel calmer and more emotionally available for nurturing relationships.

Circadian rhythm optimization extends beyond sleep to include light exposure, meal timing, and activity patterns aligned with natural day-night cycles. Morning bright light exposure, avoiding evening blue light, eating earlier in the day, and matching activity levels to circadian energy patterns all support healthy cortisol rhythms. Ashwagandha's effects on cortisol work synergistically with circadian optimization.

Long-Term Perspectives: Healthspan and Longevity

While the 60-day study demonstrated clear benefits, the long-term implications for healthspan and longevity deserve consideration.

Chronic HPA axis dysregulation and elevated cortisol represent major drivers of accelerated aging. Cortisol promotes telomere shortening in immune cells and other tissues, a hallmark of biological aging. It increases oxidative stress and inflammation, both central to aging processes. It impairs mitochondrial function, reducing cellular energy production. It drives epigenetic changes that alter gene expression patterns in ways associated with aging.

By normalizing cortisol levels, ashwagandha could slow these aging processes. While 60 days is too brief to detect effects on aging biomarkers like telomere length, sustained use over months to years might produce measurable impacts on biological age relative to chronological age.

The testosterone support in men carries longevity implications. Low testosterone correlates with increased mortality risk from multiple causes including cardiovascular disease, metabolic syndrome, and frailty. While the causal relationships remain debated, maintaining healthy testosterone levels throughout middle age and beyond likely contributes to extended healthspan.

Anxiety and stress themselves predict mortality independent of other risk factors. Chronic anxiety increases cardiovascular event risk, impairs immune function leading to increased infection and cancer risk, and associates with accelerated cognitive decline. By reducing anxiety substantially, ashwagandha might extend not just quality of life but also lifespan.

The combination of reduced cortisol, improved stress resilience, better sleep (documented in other ashwagandha studies), and maintained hormonal function creates conditions for healthy aging. Rather than viewing ashwagandha solely as a treatment for current symptoms, it might be conceptualized as a longevity intervention that helps maintain more youthful hormonal patterns despite the stressors of modern life.

The safety profile supporting long-term use enhances this perspective. Unlike interventions that prove safe short-term but problematic with extended use, ashwagandha's thousands of years of traditional use and clean safety record in modern trials suggest sustained supplementation presents minimal risk for most people.

Conclusion: A Validated Adaptogen for Hormonal Balance

This 60-day randomized, double-blind, placebo-controlled study provides compelling evidence for ashwagandha's effects on stress, anxiety, and hormonal balance. The research demonstrated:

• Significant 41% reduction in anxiety symptoms measured by the Hamilton Anxiety Rating Scale, with a strong trend toward improvement on the Depression, Anxiety, and Stress Scale-21
• Profound 23% reduction in morning cortisol levels, indicating genuine modulation of HPA axis activity rather than simple symptom suppression
• Significant 8% reduction in DHEA-S, suggesting broad effects on adrenal steroid production and stress response systems
• Meaningful 11% increase in testosterone in men, potentially counteracting age-related decline and supporting vitality
• No change in testosterone in women, appropriately reflecting different hormonal physiology
• Perfect safety record with zero adverse events and 100% study completion
• Excellent tolerability supporting long-term use
• Effects at a modest 240 mg daily dose, lower than commonly used 600 mg doses

The hormonal findings illuminate ashwagandha's mechanisms of action. Rather than targeting a single pathway, it appears to modulate the fundamental neuroendocrine systems governing stress response and hormonal balance. The coordinated effects on cortisol, DHEA-S, and testosterone suggest sophisticated influence on both the hypothalamic-pituitary-adrenal axis and hypothalamic-pituitary-gonadal axis.

These mechanisms explain the broad symptom improvements participants experienced. Reduced anxiety, better stress management, improved mood, and enhanced vitality all flow naturally from more favorable hormonal balance. The effects extend beyond subjective feelings to objective biological changes that support long-term health.

For the millions experiencing chronic stress, anxiety, hormonal imbalance, or concerns about aging, ashwagandha offers a scientifically validated tool that addresses root causes rather than merely suppressing symptoms. Its combination of efficacy, safety, and multi-system benefits distinguishes it from interventions targeting single pathways or producing benefits alongside significant drawbacks.

The convergence of ancient wisdom and modern science exemplified by this research provides confidence in ashwagandha's role in contemporary health optimization. Ayurvedic medicine has used this herb for thousands of years, observing its rejuvenating and stress-reducing properties across countless individuals. Modern research now validates these traditional observations while providing the mechanistic understanding and precise dosing needed for optimal application.

In an era of unprecedented stress loads, hormonal disruption, and chronic disease, interventions that restore fundamental balance become increasingly valuable. Ashwagandha represents such an intervention: time-tested, scientifically validated, mechanistically understood, safe for long-term use, and capable of supporting the hormonal foundations of health, resilience, and vitality.

Explore Fathom Nutrition's research-backed supplements, including standardized ashwagandha extracts matching those used in clinical research, comprehensive formulas supporting hormonal health, sleep optimization products, and nutritional foundations for optimal wellness. From targeted interventions to foundational support, Fathom Nutrition provides the tools to complement your commitment to health optimization and support your journey toward balanced hormones, enhanced resilience, and sustained vitality.

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References: Lopresti AL, Smith SJ, Malvi H, Kodgule R. An investigation into the stress-relieving and pharmacological actions of an ashwagandha (Withania somnifera) extract: A randomized, double-blind, placebo-controlled study. Medicine (Baltimore). 2019 Sep;98(37):e17186. doi: 10.1097/MD.0000000000017186