The sum of your free cortisol measurements throughout one day.
Daily Free Cortisol and Cortisone + Metabolites (Urine) - DUTCH
This section of the DUTCH test evaluates your body’s daily stress hormone patterns by measuring free cortisol, free cortisone, and their metabolites.
It answers five key questions:
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What is the overall free cortisol pattern across the day?
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What is the total free cortisol for the day?
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What is your Cortisol Awakening Response (CAR)?
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What is the total amount of cortisol metabolites?
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Does your body prefer to produce active cortisol or inactive cortisone?
Understanding the Cortisol Awakening Response (CAR)
The Cortisol Awakening Response reflects how sharply cortisol rises in the first 30–40 minutes after waking.
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Normal pattern: Cortisol peaks shortly after waking, then gradually declines through the day, reaching its lowest point at night.
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CAR calculation: The difference between your waking cortisol sample and the one collected 30–40 minutes later.
Why it matters:
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Low or flat CAR may suggest low HPA axis activity (underactive stress response) and can be linked to fatigue, burnout, sleep disorders, PTSD, and certain chronic illnesses.
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High CAR can indicate an overactive HPA axis, often associated with stress, inflammation, pain, or blood sugar instability.
You can view your CAR visually in the cortisol chart in your DUTCH report.
What Free Cortisol and Cortisone Show
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Free cortisol – the biologically active stress hormone circulating in your system (~1% of total cortisol).
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Free cortisone – the inactive form of cortisol.
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Cortisol metabolites – breakdown products representing over 70% of total cortisol output. These are often the best indicators of overall adrenal gland activity.
Why Measure Metabolites and Preferences
The DUTCH test not only measures totals but also determines metabolic preference:
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Cortisol preference → more active hormone in circulation
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Cortisone preference → more hormone is converted into the inactive form for excretion
Common Cortisol Patterns and What They May Mean
1. Low free cortisol + low metabolites
→ Suggests low overall cortisol production (possible adrenal insufficiency or suppressed HPA axis).
2. Low free cortisol + high metabolites
→ Indicates increased cortisol clearance (seen in obesity or hyperthyroidism, including overtreatment with thyroid medication).
3. High cortisol all day
→ May require evaluation for Cushing’s disease or adrenal/pituitary tumors.
4. High morning cortisol + high metabolites, but normal evening levels
→ HPA axis is overactive early in the day, not necessarily due to tumors. Often linked to chronic stress.
5. High evening cortisol
→ Suggests disrupted HPA axis rhythm and may require lifestyle or therapeutic interventions to support healthy cortisol decline.
6. Low free cortisol + flat pattern + high metabolites with cortisone preference
→ Your body produces cortisol but quickly deactivates it into cortisone. Seen in obesity or hyperthyroidism.
7. High-normal free cortisol + high CAR + cortisol metabolite preference
→ May occur in inflammation, low thyroid function, or certain adrenal conditions. The body produces cortisol but struggles to deactivate it.
Active vs. Inactive Metabolite Preference
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THF (tetrahydrocortisol) = active cortisol metabolite
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THE (tetrahydrocortisone) = inactive cortisone metabolite
In general:
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If cortisol is low → better to lean toward cortisol preference
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If cortisol is high → better to lean toward cortisone preference to avoid excessive active hormone effects
Special Note: Cortisol Cream Contamination
If topical hydrocortisone cream is applied (especially at night), it can artificially elevate evening cortisol results.
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If cortisone levels rise along with cortisol: This is likely true physiological production.
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If cortisone stays low: The spike in cortisol may be due to topical cream contamination.
Key Takeaways
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The DUTCH test evaluates both free and metabolized cortisol to give a full picture of stress hormone production and clearance.
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The Cortisol Awakening Response offers insights into your HPA axis health and stress resilience.
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Metabolic preference (cortisol vs cortisone) helps explain whether your body is activating or deactivating cortisol more aggressively.
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Results must be interpreted in context, especially if kidney function, topical steroid use, or other medical conditions are factors.
Biomarkers in this category
35 biomarkers · optimal ranges shown
a secondary, confirmatory marker for the up-and-down pattern of free cortisol
1 of the 3 cortisol metabolites. Active form.
a-THF
A metabolite of cortisol
A metabolite of cortisol
1 of the 3 cortisol metabolites. Inactive form.
1 of the 3 cortisol metabolites. Inactive form.
This is the first sample upon waking up and the value represents cortisol for the entirety of the night.
This is the 2nd cortisol sample of the day. Usually measured 30 to 60 minutes after waking.
This is the 3rd cortisol sample of the day (=afternoon levels)
Cortisol Clearance Rate (CCR) is a ratio on the DUTCH report that shows how quickly your body is metabolizing and clearing cortisol by comparing total cortisol metabolites (THF + THE) to free cortisol and cortisone measured over the day. A higher ratio means faster clearance, which can make free cortisol appear low even when production is high, while a lower ratio means slower clearance, which can leave free cortisol elevated and “feel” like high cortisol. CCR provides important context for symptoms such as fatigue, sleep issues, mood changes, weight shifts, and stress tolerance, and is best interpreted alongside related markers like 24-hour free cortisol, metabolized cortisol, and the Cortisol Awakening Response (CAR). Factors such as thyroid function, liver/kidney metabolism, BMI, stimulants, and medications can all influence CCR, which is why it should not be interpreted in isolation but rather with your full report and clinical guidance.
This is the 4th cortisol sample of the day (=evening/night)
a secondary, confirmatory marker for Cortisol A (Waking)
a secondary, confirmatory marker for Cortisol B (Morning)
a secondary, confirmatory marker for Cortisol C (Afternoon)
a secondary, confirmatory marker for Cortisol D (Night)
Best reflects total cortisol production.
Best reflects total cortisol production.
Cortisol is a stress hormone produced by the adrenal glands.
The test also offers an optional Insomnia Cortisol measurement, which is particularly relevant for individuals experiencing sleep disturbances. This additional salivary sample, known as the "Insomnia Sample," is collected in the middle of the night when the patient is struggling to sleep. It's designed to determine cortisol’s potential role in sleep disturbances. Elevated cortisol levels during this period can suggest that cortisol imbalances may be contributing to insomnia. This measurement provides valuable additional information about cortisol’s potential causal role in sleep disturbances.
This measurement offers valuable additional information about cortisol’s potential causal role in sleep disturbances. When people suffer from insomnia, the 5 salivary cortisol measurements on the DUTCH Plus may not be enough to assess cortisol’s potential role in the sleep disturbances. This additional marker can give you insight into cortisol levels during the night.
Cortisol is a stress hormone produced by the adrenal glands.
This is the 2nd cortisol sample of the day. Usually measured 30 to 60 minutes after waking.
Cortisol is a stress hormone produced by the adrenal glands.
Cortisol is a stress hormone produced by the adrenal glands.
A stress hormone produced by the adrenal glands
The inactive or “storage form” of adrenal glucocorticoid. Can be reversibly transformed to cortisol. Clinically, cortisone may reflect a measure of adrenal reserve when compared to cortisol. Ideally, cortisone will be about 30% higher than cortisol when both are at optimal levels.
The Saliva Cortisone - Extra 1 marker on the DUTCH Plus panel from Precision Analytical is a specific test that measures the level of cortisone in saliva. Cortisone is a hormone produced by the body as a metabolite of cortisol, which is often referred to as the "stress hormone." Cortisol plays a crucial role in helping the body respond to stress, regulate metabolism, reduce inflammation, and assist with memory formulation. It is produced by the adrenal glands, which are small glands located above each kidney. In the body, cortisol is converted into cortisone by an enzyme called 11β-Hydroxysteroid dehydrogenase. By measuring cortisone levels in the saliva, the test provides insights into the functioning of this enzyme and the adrenal glands' activity. Elevated levels of cortisone can indicate various conditions, including high stress, adrenal hyperactivity, and metabolic or inflammatory issues. This test is particularly useful for healthcare providers to evaluate adrenal function and stress response, allowing them to diagnose and manage potential health issues effectively. It's important for patients, especially those experiencing symptoms like fatigue, weight gain, or mood swings, to discuss their results with a healthcare provider to understand the broader context of their hormonal health.
The marker "Saliva Cortisone - Insomnia" provides a unique and insightful perspective into the complex relationship between cortisol metabolism and sleep disorders, such as insomnia. Cortisone, measured through saliva in this context, is a less active metabolite of cortisol, the primary stress hormone produced by the adrenal glands. Cortisol is crucial for various bodily functions, including the regulation of sleep-wake cycles, blood sugar levels, inflammation, and the body’s response to stress. In individuals with insomnia, cortisol levels can be dysregulated, leading to an imbalance that affects sleep quality and duration. This pattern is critical for understanding an individual's stress response and adrenal function, which can be directly linked to sleep disturbances. By analyzing saliva cortisone, healthcare providers can identify abnormalities in cortisol metabolism that may contribute to insomnia, facilitating targeted interventions to restore hormonal balance and improve sleep.
The inactive or “storage form” of adrenal glucocorticoid. Can be reversibly transformed to cortisol. Clinically, cortisone may reflect a measure of adrenal reserve when compared to cortisol. Ideally, cortisone will be about 30% higher than cortisol when both are at optimal levels.
The inactive or “storage form” of adrenal glucocorticoid. Can be reversibly transformed to cortisol. Clinically, cortisone may reflect a measure of adrenal reserve when compared to cortisol. Ideally, cortisone will be about 30% higher than cortisol when both are at optimal levels.
The inactive or “storage form” of adrenal glucocorticoid. Can be reversibly transformed to cortisol. Clinically, cortisone may reflect a measure of adrenal reserve when compared to cortisol. Ideally, cortisone will be about 30% higher than cortisol when both are at optimal levels.
The inactive or “storage form” of adrenal glucocorticoid. Can be reversibly transformed to cortisol. Clinically, cortisone may reflect a measure of adrenal reserve when compared to cortisol. Ideally, cortisone will be about 30% higher than cortisol when both are at optimal levels. ------------------ Saliva Cortisone - Waking level is a crucial indicator of adrenal gland function and the body's response to stress. Cortisone is a metabolite of cortisol, the primary stress hormone, and its levels in saliva upon waking can provide significant insights into the health of the hypothalamic-pituitary-adrenal (HPA) axis. Normally, both cortisol and cortisone follow a diurnal pattern, peaking in the early morning shortly after waking – this is part of the body's natural circadian rhythm, preparing the individual for the day's activities. Measuring waking saliva cortisone levels is particularly useful for evaluating adrenal function, stress response, and potential HPA axis dysregulation. Alterations in these levels can indicate conditions such as adrenal insufficiency, chronic stress, HPA axis dysfunction, or circadian rhythm disturbances. These assessments are valuable in diagnosing and managing conditions related to chronic stress, fatigue, and other stress-related disorders. Understanding saliva cortisone levels, especially in conjunction with cortisol levels and other hormonal assessments, helps healthcare providers develop comprehensive treatment strategies addressing adrenal health and overall well-being.
Saliva Cortisone Total on a DUTCH (Dried Urine Test for Comprehensive Hormones) test measures the overall amount of cortisone present in saliva over a specified period, usually a day. Cortisone is a metabolite of cortisol, the body's primary stress hormone, produced by the adrenal glands. This measurement is crucial in assessing adrenal gland function and the body's stress response. Unlike single-point measurements, the total cortisone level provides a broader view of how cortisone levels fluctuate and are maintained throughout the day, offering insights into the health of the hypothalamic-pituitary-adrenal (HPA) axis and the body’s circadian rhythm. Abnormal total cortisone levels can indicate various conditions such as adrenal insufficiency, chronic stress, HPA axis dysregulation, or disturbances in circadian rhythms. It’s particularly important in understanding conditions related to stress, fatigue, and cortisol-cortisone balance disorders. When interpreted alongside other hormone levels and metabolites measured in the DUTCH test, Saliva Cortisone Total can help healthcare providers develop comprehensive diagnostic and treatment plans addressing adrenal health, stress management, and overall hormonal balance.