Cortisol Tests

The major lab test used to diagnose Adrenal Fatigue is, as you might have guessed, the cortisol test. But
there is more than one type of cortisol testing, and the correct interpretation of results is also
important.
Depending on his or her preference, your doctor may order a saliva, blood or urine test to measure
your cortisol. These days it is generally accepted that saliva cortisol testing is the most accurate, as it
gives a better estimate of the cortisol levels within your cells, where the hormone reactions are actually
taking place. Remember that it is important to be well-hydrated before you do your saliva test
dehydration can skew the results.
Heres another important thing to know about cortisol testing. Taking a single measurement, or even a
24-hour average, is not enough. The best cortisol tests take 4 individual samples at various points of
the day and then map your cortisol levels over the course of a 24 hour cycle. Our cortisol levels vary
dramatically, starting high when we wake up and then tapering off until they reach their lowest point
late at night. This usually represents something like an 80% drop, which is perfectly normal. Your health
care professional needs to see not just your average cortisol level, but also the size of the morning
spike and how sharply it drops off afterwards.
Interpreting the results correctly can be difficult for a physician without experience of Adrenal Fatigue.
The reference ranges supplied by labs are so wide that they only flag up extremely low cortisol levels.
So your doctor will need to look at the levels provided and make his or her own judgment. This is where
the importance of using an optimal range, rather than the reference range, becomes clear.
Lastly, your health care professional should be aware that more than on cortisol test will be necessary
during your treatment for Adrenal Fatigue. Once you have been diagnosed and started on a treatment
course, saliva cortisol testing is a good way to monitor progress as your cortisol levels begin to return
to normal.
Saliva Testing for Adrenal Evaluation (Dr. Julie Chen)
Salivary cortisolan alternative to serum cortisol determinations in dynamic function tests
(Aardal-Eriksson et al, 1998)
Are Saliva Tests Any Good? (Dr. Andrew Weil)
Saliva Tests for Adrenal Stress (Official Website of John Lee, M.D.)

ACTH Challenge
This is another kind of cortisol test that can be very useful for your doctor. First, your baseline cortisol
levels are measured. Then, a dose of ACTH (adrenal corticotrophic hormone) is injected. Finally, your
cortisol levels are measured again.
The ACTH has the effect of stimulating your adrenal hormone output, just like it would if you were
placed in a stressful situation. This test allows you to see the response of your adrenals to stress. If
your cortisol exhibits a healthy spike higher (at least double in a blood test), your adrenals are probably
in reasonably good shape. If the spike in cortisol is not so large, this suggests adrenal insufficiency.
ACTH (cosyntropin) stimulation test (Dr. Nancy Rennert)
ACTH Challenge Test (MedicalHealthTests.com)

Thyroid Tests
You might wonder what the point of a thyroid test is, when we are looking to diagnose Adrenal Fatigue?
The complexity of the human body means that one part of the endocrine system (the HPA axis) cannot
exist independently of another part (the thyroid). In reality, there are connections and relationships
that exist between every system in the body, and a weakness in one area can easily translate into
changes in another.
In the case of Adrenal Fatigue, it has been shown that a weakening in the hypothalamus and pituitary
gland (the other parts of the HPA axis) can lead to lower thyroid function. In other words, if your blood
tests suggest mild hypothyroidism, the underlying problem might actually be Adrenal Fatigue.
There are a number of different tests for thyroid function, all blood tests. Here Im going to give a brief
summary of the most important ones. As with the cortisol test, your doctor should be looking beyond
the reference ranges provided by the lab. In fact, these days its very common for someone to be
diagnosed with mild hypothyroidism even if all their results are within the range.
Thyroid Function Tests (National Endocrine and Metabolic Diseases Information Service)
Thyroid Function Tests (American Thyroid Association)

TSH
Thyroid stimulating hormone is produced by the pituitary gland in response to instructions from the
hypothalamus. As its name suggests, TSH stimulates the thyroid to produce T3 and T4, the two most
important thyroid hormones.
The level of TSH is inversely proportional to the activity of your thyroid. If your thyroid is producing lots
of T3 and T4, your pituitary gland produces less TSH (because the thyroid needs to be stimulated less).
Conversely, if you are hypothyroid then your TSH is likely to be high, as your brain is telling the thyroid
to produce more hormones. This is the same kind of feedback loop that exists for many other
hormones in the body, including cortisol.
In the case of Adrenal Fatigue sufferers their thyroid is often performing weakly, so they will typically
have a TSH reading of above 2.0. Note that the reference range provided by the lab will usually be
around 0.50 4.50. Once again you can see the importance of looking for an optimal level rather than
just blindly following the lab ranges.

Free T3 (FT3)
This is a test that is rarely conducted by doctors, and even then usually only on hyperthyroid patients.
However it can give a useful insight into the overall function of the thyroid. T3 is produced when TSH
stimulates the thyroid. When used in conjunction with the other thyroid tests, this helps to give a
complete picture of why the thyroid is underperforming. Optimal values should be somewhere in the
300-450 pg/ml range. However, the typical lab range allows values as low as 230 pg/ml.

Free T4 (FT4)
Similarly to T3, this hormone is produced when TSH stimulates the thyroid. Your thyroid makes much
more T4 than T3, but T4 tends to have less of an effect on the body than T3 does. If your thyroid is
producing too little T4, often your TSH level will be higher. This test measures Free T4, which is
unbound and available for immediate use.

Total Thyroxine (TT4)

This test should be used along with the Free T4 test. While Free T4 measures the amount of unbound
and available T4 in your blood, Total Thyroxine also includes the amount of T4 that is bound to carrier
proteins (essentially held in reserve). Using this test together with the Free T4 test will tell you how

much T4 is available for your body to use, and how much is being held in reserve.

Tests used by integrative doctors

In addition to the tests listed above, there is a selection of tests that provide more of an insight into the
relative levels of different hormones or neurotransmitters in your body. These will rarely be ordered by
a medical doctor, but your integrative doctor or naturopath may ask for them.

Cortisol / DHEA Ratio

This test tells us which point along the Adrenal Fatigue pathway the patient might have reached. In the
initial stages of a stress reaction both cortisol and DHEA will be high. But as the body begins to struggle
to produce sufficient stress hormones, DHEA levels start to fall. Put very simply, this is because the
stress hormone production steals resources from the sex hormone production. Further on in the
development of Adrenal Fatigue, cortisol levels will begin to drop too. So this ratio, combined with
other tests and information, helps us to determine which stage of Adrenal Fatigue the patient has
reached.

17-HP / Cortisol Ratio

17-hydroxyprogesterone (17-HP) is a precursor to cortisol, in other words one of the raw materials that
the body uses to create cortisol. In Adrenal Fatigue sufferers it is common to see higher levels of 17-HP
vs. cortisol, as the adrenals struggle to make this conversion happen.

Neurotransmitter Testing
Ive spoken exclusively about hormones so far, but neurotransmitters are another important part of
our endocrine system. These chemical messengers transmit messages between our cells and, just like
cortisol, they can become depleted after long periods of stress. With recent developments in testing
procedures it is now possible to compare a patients neurotransmitter levels to a reference range for
healthy patients. This test is usually conducted first thing in the morning and is best accomplished via a
urine test. It is only available from a small number of labs.
Functional Adrenal Stress Profiles (BioHealth Laboratory)
Adrenocortex Stress Profile (Genova Diagnostics)

Alternative Tests
When Adrenal Fatigue was first diagnosed many of these tests did not even exist. To help provide a
diagnosis, doctors developed a series of more physical tests that can be conducted quickly in a doctors
clinic or at home. These tests are clearly much less accurate than the blood, saliva and urine tests
mentioned above, and positive results may reflect other health problems besides Adrenal Fatigue.
However they can be a useful diagnostic tool in combination with all the other evidence provided.

The Iris Contraction Test

First described by Dr. Arroyo in 1924, this test measures the contraction of the iris in response to
repeated exposure to dark light. In those with weakened adrenal function, the theory goes that the iris
will be unable to maintain its contraction for long.
To conduct the test, sit in a darkened room, in front of a mirror. Take a flashlight and shine it across
your eye, from the side of your face. In a hypoadrenal state, your pupil will not be able to hold onto its
contraction for more than 2 minutes and thus will begin to dilate despite light repeatedly shining on it.
In those with healthy adrenals, the contraction should last much longer.

Postural Low Blood Pressure

When we stand up, those of us who are in good health experience an almost immediate rise in blood
pressure. In contrast, Adrenal Fatigue sufferers will see no change in their blood pressure, or even a
slight fall. In very general terms, a larger drop in blood pressure signifies a more severe case of Adrenal
Fatigue.
This is a very simple test to do at home. Use your regular blood pressure monitor and check your blood
pressure while lying down. Then stand up and conduct the test again.