Daily Free Cortisol and Cortisone + Metabolites (Urine) - DUTCH
Urine
Performed by: Precision Analytical (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.
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Biomarkers included in this panel:
Cortisol is a steroid produced and secreted by the adrenal glands. A very small percentage of cortisol is free and unbound, while the remaining is in transition. The human body produces cortisol first, and then different glands have the ability to
Learn moreCortisone is the inactive form of cortisol. Cortisone shows minimal biological activity per se, reflecting negligible affinity for the glucocorticoid and aldosterone receptors. The kidney, colon and saliva gland have lots of activity for changing cor
Learn moreThis is one of the three cortisol metabolites. The total some of the three cortisol metabolites gives us a good indication of the overall cortisol production in your body. Two of the 3 metabolites are the active form of cortisol (THF). The o
Learn moreMetabolized cortisol is the sum of a-tetrahydrocortisol (a-THF), b-tetrahydrocortisol (b-THF), and b-tetrahydrocortisone (b-THE). They are a good indication of the total cortisol output from the adrenal gland or clearance out the body.
Learn moreB-Tetrahydrocortisol [aka 5-beta-Tetrahydrocortisol (5b-THF)] is a metabolite of cortisol. Tetrahydrocortisone, Tetrahydrocortisol and Allo-Tetrahydrocortisol are cortisol metabolites that reflect approximately 50% of daily cortisone synthesis. Th
Learn moreB-Tetrahydrocortisol [aka 5-beta-Tetrahydrocortisol (5b-THF)] is a metabolite of cortisol. Tetrahydrocortisone, Tetrahydrocortisol and Allo-Tetrahydrocortisol are cortisol metabolites that reflect approximately 50% of daily cortisone synthesis. Th
Learn moreThis is one of the three cortisol metabolites. The total some of the three cortisol metabolites gives us a good indication of the overall cortisol production in your body. Two of the 3 metabolites are the active form of cortisol (THF). The o
Learn moreThis is one of the three cortisol metabolites. The total some of the three cortisol metabolites gives us a good indication of the overall cortisol production in your body. Two of the 3 metabolites are the active form of cortisol (THF). The o
Learn moreCortisol is a hormone produced by the adrenal glands, which are located on top of the kidneys. It is normally released in response to events and circumstances such as waking up in the morning, exercising, and acute stress. In the Dutch test there
Learn moreThis is the 2nd cortisol sample of the day. Usually measured 30 to 60 minutes after waking. Cortisol is a hormone produced by the adrenal glands, which are located on top of the kidneys. It is normally released in response to events and circ
Learn moreThis is the 3rd cortisol sample of the day. Usually measured in the afternoon. Cortisol is a hormone produced by the adrenal glands, which are located on top of the kidneys. It is normally released in response to events and circumstances suc
Learn moreThis is the 4th cortisol sample of the day (=evening/night). Cortisol is a hormone produced by the adrenal glands, which are located on top of the kidneys. It is normally released in response to events and circumstances such as waking up in t
Learn moreCortisone is the inactive form of cortisol. Cortisone shows minimal biological activity per se, reflecting negligible affinity for the glucocorticoid and aldosterone receptors. The kidney, colon and saliva gland have lots of activity for changing cor
Learn moreCortisone is the inactive form of cortisol. Cortisone shows minimal biological activity per se, reflecting negligible affinity for the glucocorticoid and aldosterone receptors. The kidney, colon and saliva gland have lots of activity for changing cor
Learn moreCortisone is the inactive form of cortisol. Cortisone shows minimal biological activity per se, reflecting negligible affinity for the glucocorticoid and aldosterone receptors. The kidney, colon and saliva gland have lots of activity for changing cor
Learn moreCortisone is the inactive form of cortisol. Cortisone shows minimal biological activity per se, reflecting negligible affinity for the glucocorticoid and aldosterone receptors. The kidney, colon and saliva gland have lots of activity for changing cor
Learn moreMetabolized Cortisol is the sum of a-THF, b-THF and b-THE (the most abundant cortisol metabolites). While free cortisol is the best assessment for tissue levels of cortisol, it only represents 1-3% of the total produced. The majority of cortisol r
Learn moreMetabolized cortisol best reflects total cortisol production.
Learn moreCortisol is a stress hormone produced by the adrenal glands and is the primary agent used in our body’s flight or fight response to threatening stimuli.
Learn moreThe 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 t
Learn moreThis 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 cortis
Learn moreCortisol is a stress hormone produced by the adrenal glands and is the primary agent used in our body’s flight or fight response to threatening stimuli.
Learn moreThis is the 2nd cortisol sample of the day. Usually measured 30 to 60 minutes after waking. Cortisol is a hormone produced by the adrenal glands, which are located on top of the kidneys. It is normally released in response to events and circ
Learn moreCortisol is a stress hormone produced by the adrenal glands and is the primary agent used in our body’s flight or fight response to threatening stimuli.
Learn moreCortisol is a stress hormone produced by the adrenal glands and is the primary agent used in our body’s flight or fight response to threatening stimuli.
Learn moreCortisol is a stress hormone produced by the adrenal glands and is the primary agent used in our body’s flight or fight response to threatening stimuli.
Learn moreThe 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 referre
Learn moreThe 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
Learn moreSaliva 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 stre
Learn more