Here is one of the top questions I receive: “Dr. Sara, how should I test my cortisol? I think I may have adrenal fatigue (or adrenal burnout, or more accurately, adrenal dysregulation). There’s so many options. What’s the best?”
The short answer is: it depends. For years, I’ve been ordering a combination of different tests in individual patients, which reflect various and distinct aspects of adrenal function, but I’m now getting more interested in diurnal dried urine testing, which I’ve described briefly below (and I’ll get more into the science of it in a later blog).
Cortisol is known as the “stress hormone” because stress triggers cortisol secretion from the adrenal glands. While normal amounts are key to stable blood sugar, blood pressure, and immune function, too much can make you fat loss resistant, raise blood pressure and cardiovascular risk, poke holes in your gut, and shrink your hippocampus in your brain—where you consolidate memory and regulate emotions.
When it comes to cortisol testing, here are the best options.
- Blood/Serum. A cortisol test is done to measure the level of the hormone cortisol in the blood, which may indicate problems with the adrenal glands or pituitary gland. Ideally, perform the test around 8:00 a.m., and aim for the optimal range for adults of 10-15 mcg/dL. Perform this test with your health professional, or less ideally, order from a direct-to-consumer lab. (1) The advantage of blood testing is that it’s the universal language of conventional health professionals; the disadvantage is that it’s a 10-15 second snap shot of your stress level while the needle is in your vein, and if you have a needle phobia, the measurement may be falsely elevated. (Note that a more advanced version of the blood test is the “cort stim test” – which measures adrenal reserve. (2) Typically, this is a more advanced test performed in people with low cortisol levels to exclude Addison’s disease.)
- Saliva. There’s a diurnal pattern to your cortisol levels, which means you must be systematic about measuring your level at the same time over the next few months to years, i.e., don’t compare a 3 p.m. blood cortisol to an 8 a.m. cortisol. Compare apples to apples, and choose the best apples! Diurnal refers to a 24-hour period. Similar to how a gazania blooms in morning and closes in the evening, your cortisol rises after getting up in the morning (called the “Cortisol Awakening Response”) and should be at its lowest before bedtime. In both saliva and certain types of urine tests (see below), you can measure your cortisol at four points during the day (also known as a four-point cortisol, usually before breakfast, lunch, dinner, and bedtime) to assess your cortisol slope. You can test your cortisol in saliva at a number of direct-to-consumer labs, but my advice is to work with a trusted and collaborative health professional, because adrenal function isn’t simple and it’s rare that you can follow a do-it-yourself plan and see stellar results. (3) The advantage to saliva is convenience, but the disadvantage is that most people vary a fair amount in their salivary cortisol levels. Another disadvantage is that you’re measuring free cortisol, which is only 1% of the total cortisol load in the body. Still, you can spot trends over time and I’ve found 4-point tests to be reasonably helpful in my medical practice. Even though salivary cortisol is not readily accepted by mainstream medicine, there are thousands of studies published in peer-reviewed journals demonstrating its utility clinically. (4) While salivary 4-point cortisol used to be my most commonly ordered test, it’s now in competition with the next test, diurnal dried urine.
- Urine. Relatively fresh on the scene is diurnal urinary cortisol testing, from Precision Analytical. (5) I was first introduced to their technology in 2013, and I’m still gathering my evidence before making a stronger recommendation—but there’s a lot to love in their diurnal test. I like measuring the urinary metabolites of sex hormones because they give you a sense of the wear-and-tear from catabolic hormones such as cortisol versus the growth-and-repair from anabolic hormones such as DHEA and testosterone. You can also measure estrogen metabolites, and modulate your body’s tendency to make too much of the less-good estrogens (if you’re like me). I’ve been a little busy lately and took my time checking out the science behind Precision Analytics, but after an “I-can’t-believe-you’re-not-using it” conversation with fellow clinician Chris Kresser, I dove into the data. Chris says: “I prefer dried urine hormone testing because it combines the advantages of saliva testing (ability to measure diurnal production of cortisol) and 24-hour urine testing (ability to measure androgen and glucocorticoid metabolites in addition to the hormones themselves).” This testing employes DUTCH, which is an acronym for Dried Urine Test for Comprehensive Hormones, and you simply pee on filter paper until saturated at the proper time. Easy peasy. Regarding urine, I always love to give y’all options, so here’s another favorite: the “Complete Hormones” test, available from Genova. (6) Usually, this test is assessed on the urine from the first-morning void (again, disadvantage is that it’s a quick snapshot) or a 24-hour collection (inconvenient, and averaged over your diurnal cycle, but can provide important assessment of your cortisol load in one day).
- Hair. Hair is an interesting choice because it’s quite stable, and it’s sometimes used in stress studies published in the peer-reviewed scientific literature. I like the test from Accu-metrics (7) to measure the last 90 days of cortisol load. This may predict cardiovascular risk, and it’s a reliable measure of your allostatic load – or your ability to roll with the punches (I’m always moderately stressed, according to the test. Go figure!).
I prefer dried urine hormone testing because it combines the advantages of saliva testing (ability to measure diurnal production of cortisol) and 24-hour urine testing (ability to measure androgen and glucocorticoid metabolites in addition to the hormones themselves).
– Chris Kresser, M.S., L.Ac
My First Cortisol Test
For context, I want to share with you a quick story from my thirties, when I worked at a local Health Maintenance Organization (HMO) as a mom to two young kids, and a wife to a green rock star who travelled frequently. As if this weren’t stressful enough, I struggled with low energy, belly fat, a nonexistent libido, and a less-than-sunny disposition. As you might imagine, this was a miserable experience for all involved.
I was too young to feel so bitchy. My primary care doc offered antidepressants, but they certainly didn’t seem like the right solution. I didn’t want to dampen my dynamic range or mute the texture of my life. I just wanted to feel more alive.
I was lucky. Because of my medical training, I knew what to do. I formed a hypothesis: my hormones were off balance. In my medical education and residency, I was taught that measuring hormone levels is a waste of time and money, because hormone levels vary too much. But when I thought about how we track hormones such as estrogen, progesterone, thyroid, and testosterone when women are trying to conceive or are in the early months of pregnancy, I wondered why those numbers would be important indications of a woman’s health in one situation but not another? Wouldn’t my hormone levels be as reliable an indicator of my health after my pregnancies as before them? Why the double standard?
Rhetorical questions aside, I drew my blood-serum levels of thyroid, sex hormones including estrogen and progesterone, and cortisol. I then discovered what millions of other women face: my hormones were seriously out of whack. What surprised me most was that my blood cortisol was three times what it should have been. Yikers! I was a frazzled new mom, harried wife, and busy doctor, with significant imbalances in my estrogen, progesterone, thyroid, and cortisol levels. It didn’t stop there: downstream, the high cortisol was causing all types of mischief, including raising my blood sugar and depositing belly fat.
I fixed it in four weeks, but that’s a conversation for another time. The takeaway here is that I wouldn’t have known that cortisol was the main culprit if I didn’t measure it. You should measure your level too.
Final Word to the Wise: Get Your Doctor to Test Your Gap
Ten years ago, when I still worked in the trenches of conventional medicine, before I spun off to start my own integrative medicine practice, I figured there had to be a better way to fill the gaps that women encounter between what we struggle with and what mainstream medicine offers. I discovered that the most important gap was adrenal function. Your adrenals are the tiny little endocrine glands on top of your kidneys that secrete several stress hormones, including cortisol and DHEA. In my medical training, I learned about tumors of the adrenal glands, and what to do if a patient had an extreme excess of cortisol (Cushing’s syndrome) or complete failure of the adrenals (Addison’s disease). I had been trained to identify the weeds and dead plants, but not to look for the early and subtle signs of ailing to come.
It’s time to measure your cortisol, using one of the four methods I’ve described. What you measure improves. Your adrenals may just be the most important plants in your garden for us to nurture and help bloom. Watch for a future blog coming soon on the dried urine test for hormones, and an unbiased view of its merits and flaws. To learn more about ways to reset your hormones, order my book, The Hormone Reset Diet, right here.
(5) http://www.precisionhormones.com/. Click on this video to learn more: http://www.precisionhormones.com/?q=content/video-ii-testing-adrenal-hormones-dutch-0
(6) Genova tests must be ordered by health professionals. See https://www.gdx.net/product/complete-hormones-test-urine for more information.