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Evidence Based

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When to Use the DUTCH Test to Measure Cortisol

Written by Dr. Michael Ruscio, DC on July 22, 2024

Written by Dr. Michael Ruscio, DC on July 22, 2024 — Reviewed by Dr. Hannah Hamlin

Can the DUTCH Test Identify “Tired” Adrenal Glands?

• DUTCH Adrenal Test|
• What It Means|
• What It Can’t Do|
• When It’s Useful|
• Conventional vs. DUTCH|
• Fatigue Causes|
• Find the Root|

You may have had a naturopath or functional medicine practitioner recommend a DUTCH test to look for hormonal imbalances and health issues like chronic fatigue, chronic stress, and burnout.

DUTCH stands for Dried Urine Test for Comprehensive Hormones 1. It’s a test that can measure a wide range of sex and adrenal hormones from dried urine samples.

There are many different DUTCH tests you can buy online and then work with a practitioner to interpret. Some of these tests measure sex hormones, like estrogen and progesterone. These are often used to evaluate and monitor hormone levels in menopause patients on hormone replacement therapy (HRT). Other DUTCH tests measure organic acids, which can give clues about the body’s nutrients, such as vitamin B12.

In this article, I will investigate DUTCH Adrenal, a type of DUTCH test that looks at cortisol levels and patterns over the whole day.

You might have heard that DUTCH cortisol testing can identify conditions related to chronic stress and fatigue, like hypothalamic–pituitary–adrenal (HPA) axis dysfunction and immune dysregulation. However, as I’ll explain, the evidence doesn’t support this.

What Is the DUTCH Adrenal Test?

DUTCH tests are produced by a company called Precision Analytical, Inc. To provide samples for a DUTCH Adrenal test, you have to pee on filter paper at various points during the day and let it dry thoroughly. The analyzing lab then uses a type of mass spectrometry that can identify cortisol and its metabolites (byproducts of cortisol metabolism) from the sample 2.

The adrenal-focused DUTCH test measures the following adrenal gland hormones and metabolites to get a better sense of the body’s cortisol levels 3.

• Free cortisol: The main hormone the adrenal glands produce, with functions that include:
  • Suppressing the immune system
  • Increasing blood pressure
  • Increasing blood glucose levels
  • Promoting the breakdown of fats and proteins to provide energy during times of stress and fasting
• Cortisol metabolites: Byproducts of cortisol metabolism
• Free cortisone: The inactive form of cortisol (the adrenal glands convert active cortisol to inactive cortisone and vice versa, back and forth as needed) 
• Cortisone metabolites: Byproducts of cortisone metabolism
• DHEA (Dehydroepiandrosterone): A steroid hormone and weak androgen (‘male’ sex hormone) that inhibits cortisol and plays a role in:
  • Sexual function
  • Athletic performance
  • Bone health 

You can also add the DUTCH Cortisol Awakening Response (CAR) test. Precision Analytical claims that this early morning saliva test provides extra insight into how well the body’s HPA axis is functioning.

The DUTCH Adrenal as a stand-alone test costs $399. You can also get the adrenal panel bundled into two more comprehensive hormone test kits, called the DUTCH Complete ($499) and the DUTCH Plus ($650). 

The HPA Axis

The HPA axis or hypothalamic–pituitary–adrenal axis is a hormonal feedback mechanism involving two parts of the brain and the adrenal glands. The brain’s hypothalamus and pituitary gland triangulate communication with the adrenal glands to regulate the amount of cortisol the adrenal gland ultimately produces.

In medical conditions like Cushing’s syndrome, the HPA axis becomes hyperactive and causes high-cortisol symptoms, such as weight gain, weakness, and bone pain 4. At the other extreme, the HPA axis can become under-reactive. This causes Addison’s disease, a low-cortisol condition with symptoms like weight loss, low blood pressure, and fast heart rate 5.

What Do DUTCH Test Results Mean?

After you return your dried urine sample to their laboratory, Precision Analytical provides you with a graphic representation of your cortisol levels throughout the day. The graph they provide shows your cortisol patterns, which may look like:

• A normal cortisol curve: Cortisol levels are highest in the morning, decline as the day progresses, and reach their lowest at night, just before bed 6 7.
• A reverse cortisol curve: Cortisol levels are low in the morning, which observational research has associated with morning fatigue and feeling unrested. A “cortisol spike” appears in the evening, just before bed, which has been associated with insomnia and other sleep disturbances 8.
• A “flat-line” cortisol curve: The cortisol curve is flattened throughout the entire day, which observational research has associated with chronic fatigue, mood swings, and other negative health outcomes 9 10 11.

What DUTCH Test Results Won’t Tell You

Adrenal fatigue—a term used to describe a mild form of adrenal insufficiency caused by chronic stress—has become a popular “condition” that cortisol tests like the DUTCH test are supposed to reveal. 

Certainly, the graphs you get after taking a DUTCH Adrenal test are interesting and somewhat informative.

But research shows the DUTCH test (with or without Cortisol Awakening Response) doesn’t help identify a dysregulated immune system 10, as is often claimed. It also fails to accurately diagnose HPA-axis dysfunction, including the now-debunked concept of “adrenal fatigue” 12 13.

In fact, the evidence suggests that “adrenal fatigue,” in the sense of the adrenal gland wearing out and no longer being able to produce sufficient cortisol, is not a real condition. 

One systematic review of 58 observational studies found strong evidence that “adrenal fatigue” does not exist 12. Furthermore, the methods used in the studies (typically cortisol testing) were not capable of determining whether a patient had adrenal issues or not. 

Other research shows that we don’t know if cortisol abnormalities cause health and wellness issues, or if it’s the other way around. In a systematic review of 80 studies totaling nearly 37,000 participants, flattened cortisol levels were associated with many problems, like immune and inflammatory issues, fatigue, obesity, and depression. However, the research couldn’t identify which came first: the symptoms or the abnormal cortisol levels—and it couldn’t determine whether the symptoms were actually related to cortisol 10.

Furthermore, chronic stress symptoms don’t always correlate with abnormal cortisol levels. For example, cortisol patterns are often normal in people with PTSD (post-traumatic stress disorder) or other forms of adult trauma, which are among the worst types of chronic stress 14 15.

Fatigue and the HPA Axis: It’s Complicated

The reality is that while the adrenal glands may be involved to some degree in symptoms of fatigue and burnout caused by chronic stress, they are only one part—the “A”—of the HPA axis. So, even though disrupted cortisol levels may involve HPA-axis dysfunction, we can’t say for sure that the adrenal part of this axis is what’s failing. 

In fact, a 2018 meta-analysis of 13 MRI studies outlined how chronic stress and burnout can alter brain structures, like the hypothalamus and pituitary gland (the “H” and “P” in HPA axis). That means the problem could be rooted in these structures instead of the adrenals. 

The same study showed that chronic stress could also cause harm beyond the HPA axis. For example, it could impair neurogenesis (the formation of new neurons in the brain) and cause limbic structures (parts of the brain involved in regulation of emotions) to shrink 16.

Overall, there’s no clear evidence that stress has a direct effect on the adrenal gland or its production of cortisol. More likely, stress has farther-reaching impacts—on the complex HPA axis and beyond—that are not yet understood or measurable with cortisol testing.

That said, it’s important to note that if you and your doctor think it’s helpful to investigate possible HPA axis dysfunction, the gold standard is not a cortisol test. Instead, the best way to assess HPA axis function is by using an insulin tolerance test 12. 

What DUTCH Testing Can Do

Although the DUTCH Adrenal test can’t confirm “adrenal fatigue,” it can give your doctor an accurate cortisol level for helping to rule out (or in) true cortisol-related diseases. 

The dried urine testing unique to the DUTCH test also makes it easier for patients to collect samples (versus filling tubes with saliva) and provides details (like hormone metabolites) that other tests may not 17.

The extensive information that the DUTCH Adrenal test gives can:

• Identify clinically high cortisol in the body and help diagnose Cushing’s syndrome
• Identify clinically low cortisol and help distinguish between primary adrenal insufficiency (Addison’s disease), secondary adrenal insufficiency (pituitary gland damage), and tertiary adrenal insufficiency (brain tumor or rapid steroid withdrawal) 
• Detect licorice-induced pseudo-hyperaldosteronism (when eating too much licorice causes cortisol to mimic another hormone called aldosterone, leading to high blood pressure and low potassium without adrenal gland dysfunction)
• Provide insights into adrenal function and detect irregularities in cortisol-binding proteins, which transport cortisol in the bloodstream

In other words, DUTCH testing may be a convenient and comprehensive way to test for true cortisol-related medical conditions with accuracy.

How Do Conventional Cortisol Tests Differ From the DUTCH Test? 

Conventionally, medical professionals measure cortisol with wet urine or blood tests. These tests are analyzed using mass spectrometry, just like the DUTCH test. The conventional testing has the advantage of being FDA-approved, which DUTCH testing is not.

If you or your doctor suspect you may have a condition affecting your adrenal gland function, you’ll likely save money and get high-quality results by using conventional cortisol tests from qualified labs. There are many different tests to serve each patient’s needs.  

Depending on your results, you may be referred to an endocrinologist (doctor who specializes in hormone health), who will likely have more experience interpreting standard medical tests than the DUTCH Adrenal test.

What’s Actually Causing Your Fatigue?

Struggling with chronic fatigue is often how people find themselves down the rabbit hole of DUTCH testing. But as we’ve discovered, testing cortisol levels rarely tells us anything useful about this symptom.

Instead, fatigue patients are better off forgoing adrenal tests like the DUTCH test altogether and working with their healthcare provider to focus on the real cause(s) of fatigue.

Causes you might not expect include: 

• Gut conditions, such as:
  • IBS (irritable bowel syndrome) 18 
  • Non-celiac gluten sensitivity 19
  • Dysbiosis and gut infections 20 21
  • Leaky gut 22 23
  • IBD 18
• Hypothyroidism (underactive thyroid) 24
• Chronic sleep issues 25
• Nutrient inadequacies 26 or deficiencies 27 28 29 30
• Myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS) 31
• Certain autoimmune diseases, like autoimmune gastritis [32] and multiple sclerosis 33
• Mold illness 34 35
• Burnout or exhaustion related to chronic stress 12 13

This list isn’t comprehensive, and there are many more possible reasons for feeling fatigued. However, at the clinic, we commonly find that when people boost the health of their gut microbiome with a healthy, anti-inflammatory diet and probiotics, their fatigue symptoms start to improve. 

This fits with research finding that some people who have common gut problems, like IBS, SIBO, or leaky gut syndrome, have as much fatigue as gut symptoms 23 36 37. 

While working on gut health won’t solve every fatigue problem, it is fundamental to many aspects of good health. Supporting the gut is never a wasted investment in health.

Find the Root of Your Fatigue

Cortisol testing with the DUTCH test is only useful for assessing adrenal gland function and related conditions. It is NOT useful for diagnosing fatigue, exhaustion, or burnout.

• If you and your doctor suspect you’re dealing with a problem with the hypothalamic-pituitary-adrenal axis, cortisol testing isn’t helpful, but the insulin tolerance test may be.
• If you or your doctor suspect you may have a condition affecting your adrenal gland function, it’s probably easier and cheaper to get your cortisol tested at a qualified lab. 
• However, if you’re suffering from chronic fatigue, it’s a good idea to skip the cortisol testing and examine well-understood potential causes of fatigue with your healthcare provider. 

If you don’t yet have a physician you trust to help you find the root cause of your fatigue or other symptoms, reach out to our clinic at the Ruscio Institute for Functional Health today. You can also learn how to heal your gut and fight back against chronic fatigue in my book, Healthy Gut, Healthy You.

The Ruscio Institute has developed a range of high-quality formulations to help our clients and audience. If you’re interested in learning more about these products, please click here. Note that there are many other options available, and we encourage you to research which products may be right for you. The information on DrRuscio.com is for educational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment.