Is the DUTCH Test Useful for Measuring Cortisol Levels?

An Inside Look at Cortisol Testing and the Adrenal Fatigue Diagnosis

• What Makes the DUTCH Test Unique?|
• Is DUTCH Adrenal Test Useful?|
• Disputing Adrenal Fatigue|
• When to Use Cortisol Testing|
• 6 Common Triggers of Chronic Fatigue|
• Final Thoughts|

Many of us struggle with symptoms of low energy, sleep issues, anxiety, joint pain, and decreased motivation. In the functional medicine world, these symptoms can often result in a diagnosis of “adrenal fatigue.” 

While there’s no standardized way to evaluate this type of adrenal dysfunction, cortisol tests are often the “go-to” method. The Dried Urine Test for Comprehensive Hormones (DUTCH) is unique in that it assesses cortisol levels and patterns by sampling dried urine. The DUTCH test is not limited to cortisol testing, and evaluates other hormones, such as male and female sex hormones and their metabolites. 

DUTCH testing evaluates hormonal patterns that may be linked to reproductive disorders, infertility, and non-specific symptoms of a hormonal imbalance, like fatigue, weight gain, and brain fog. But is this dried urine testing panel actually helpful? 

DUTCH test results are likely as accurate as blood testing when it comes to measuring basic hormone levels. However, when it comes to the more unique aspects of the DUTCH test that most people are paying for (like evaluating cortisol patterns), the results are not likely to be very useful. 

In fact, research shows that cortisol testing, in general, doesn’t appear to correlate with symptoms of adrenal dysfunction.

With cortisol test results being speculative at best, what’s really occurring behind the scenes in those experiencing chronic fatigue?

The cause of chronic fatigue is likely more complex than what a single lab test can offer, and often results from our lifestyle habits or gut health imbalances. Fortunately, there are several common triggers that may be contributing to your symptoms.

What Makes the DUTCH Test Unique?

The current gold standard for assessing hormones is through measuring serum blood levels, as it offers accurate results. However, getting to a lab can be time-consuming and many people are hesitant to undergo a blood draw. 

The DUTCH test may provide a simpler and less-invasive testing method that looks at hormone levels in dried urine. This testing process claims to offer a more in-depth analysis of your hormone levels, as it also evaluates for hormone metabolites, unlike most serum blood tests [1, 2, 3, 4]. 

It also avoids the cumbersome method of saliva testing, which requires you to fill an entire test tube with saliva during collection. 

The DUTCH test is also unique in that it often evaluates hormone levels at multiple points throughout the day and/or month for a more detailed analysis. Some of the most popular tests focus on male and female sex hormones, such as:

• Estrogen (estrone, estradiol, and estriol)
• Progesterone
• Androgens (testosterone and DHEA)

The DUTCH test is often used to evaluate for hormonal disorders like PCOS, estrogen dominance, PMS, and menopause. However, DUTCH testing offers a wide range of hormone testing, and the cortisol test, in particular, claims to give insight into chronic fatigue. 

DUTCH Cortisol Testing

The DUTCH Adrenal Panel test measures free cortisol, cortisol metabolites (like cortisone), and other adrenal stress hormones in your urine. The test kit is mailed to your home, where you collect dried urine samples at four points during the day:

1. Upon first waking in the morning
2. Late morning
3. Afternoon, ideally when you experience any drops in energy post-lunch
4. In the evening, right before bed

These urine samples are dried on a card and mailed back to the laboratory. By taking four samples, the company can provide you with a graphic representation of your cortisol levels throughout the day. This graph can identify diurnal cortisol patterns, such as:

• The Cortisol Curve: A normal pattern with the highest levels of cortisol levels present in the morning. Levels decline as the day progresses and reach their lowest at night, just before bed [5, 6].
• The Reverse Pattern: Cortisol levels are low in the morning, which is attributed to AM fatigue and feeling unrested. This is combined with a “cortisol spike” in the evening, just before bed, and is thought to be associated with insomnia and other sleep disturbances [7].
• The “Flat-Line” Pattern: Persistently low cortisol levels throughout the entire day, associated with chronic fatigue, depression, and other negative health outcomes [8, 9, 10].

These patterns, along with other cortisol irregularities, can be mapped out by the DUTCH test, and are frequently considered to be indicative of adrenal fatigue and chronically low energy levels. But do these variances in cortisol rhythms translate well to clinical application?

Is the DUTCH Test Useful?

Several studies validate that dried urine testing is likely as accurate as serum blood levels for evaluating hormone levels [11, 12, 13]. And while this may make DUTCH testing an accurate alternative to more invasive serum testing, it’s often not covered by insurance and can be expensive.

It’s also important to note that the studies that determined dried urine testing to be as accurate as serum testing were performed by Precision Analytics— the company that offers the DUTCH test.

Furthermore, there’s currently a lack of standardized reference ranges among labs that offer dried urine, saliva, and dried blood-spot hormone testing [14, 15, 16, 17]. This can make the interpretation of test results challenging, as there’s very little indication of what “normal” levels actually are.

These obstacles make it difficult to apply DUTCH cortisol testing in a clinical setting, along with no research evidence that identifying abnormal cortisol patterns can be useful for giving practical treatment recommendations. The information gathered from these tests may be interesting, but also may be unreliable when trying to treat your symptoms.

The Pitfalls of Cortisol Tests

Unfortunately, the current research reveals that cortisol levels don’t appear to correlate with patient symptoms, including chronic fatigue. One meta-analysis (which offers the highest quality of evidence), showed that 50-80% of patients’ symptoms were not supported by abnormalities in cortisol testing. In fact, those with chronic fatigue showed no difference in cortisol levels than healthy controls [18].

Furthermore, cortisol testing may be inaccurate in detecting adrenal dysfunction, immune issues, and other related conditions [9, 18, 19].

These studies highlight the importance of treating the patient’s symptoms, rather than a test result. Lab values don’t always correlate with how the patient feels, and when the focus remains on correcting test results, we’re likely missing the bigger picture. 

Practitioners may even give inappropriate treatment recommendations when relying solely on lab results. For example, prescribing calming supplements to someone who feels very fatigued, but has elevated cortisol levels. Test results can offer important information and insight to someone’s symptoms, but they shouldn’t be the end-all-be-all when diagnosing and treating. 

While urine hormone testing may offer an accurate alternative to more invasive serum tests, its usefulness in diagnosing adrenal dysfunction is likely speculative at best. Instead, these results should be used more like guidelines, rather than rules, when treating someone’s symptoms. 

It’s more important to focus on the underlying health conditions and lifestyle factors that may be contributing to chronic fatigue, like sleep issues, chronic stress, and poor gut health.

The Theory Behind Adrenal Fatigue

Many functional medicine practitioners and independent laboratories support the theory of adrenal fatigue, and suspect that cortisol dysregulation is at the root of chronic fatigue. They attribute a broad array of non-specific symptoms to an adrenal fatigue diagnosis, including:

• Chronic fatigue and weakness
• Low motivation
• Sleep disturbances and insomnia
• Memory loss, brain fog, and other cognitive issues
• Anxiety, depression, and other mood disorders
• Low blood pressure
• Blood sugar imbalances

Cortisol is a powerful anti-inflammatory hormone that plays an extremely important role in many of our body’s normal functions, like our stress response and sleep-wake cycles. It even influences blood sugar levels, immune system function, and our mood [20].

Cortisol is secreted by the adrenal glands, along with other hormones like aldosterone and DHEA [20]. Supporters of the adrenal fatigue diagnosis state that disturbances in these hormones indicate a decline in adrenal function. They believe that testing for cortisol levels and other adrenal hormones can help resolve chronic fatigue and other non-specific health symptoms.

However, there’s little research evidence that adrenal fatigue actually exists [18], and the causes of chronic fatigue are likely more complex than just having an abnormal cortisol pattern. It may be more useful to think of adrenal fatigue as burnout syndrome, and to identify the underlying factors that lead to burnout. 

When Cortisol Testing Is Helpful

There are several medically recognized conditions that often require cortisol testing. Addison’s disease is an autoimmune condition that causes extremely low cortisol levels [21], and is often accompanied by symptoms like [22]:

• Extreme fatigue
• Weight loss and loss of appetite
• Darkening of skin color
• Low blood pressure, dizziness, lightheadedness, or fainting
• Low motivation and mood
• Muscle weakness
• Intensified thirst
• Hormonal and blood sugar imbalances

Cushing’s disease and Cushing’s syndrome are characterized by abnormally elevated levels of cortisol that present with [23]:

• Weight gain and increased fat, particularly on the upper back and face
• Blood sugar disturbances and type 2 diabetes
• Stretch marks and slow-healing skin
• High blood pressure
• Mood swings and anxiety
• Insomnia
• Decreased bone density

ACTH and dexamethasone-suppression tests, 24-hour urine collection, and antibody testing are special types of cortisol response testing, and are the gold standard in diagnosing Addison’s and Cushing’s disease [21, 24]. However, these tests are very involved and should be performed only under a doctor’s supervision. Other forms of cortisol testing, such as dried urine, salivary, and dried blood-spot testing are not approved to diagnose Addison’s or Cushing’s disease.

And while these disorders are relatively rare [25], if you suspect that you have either of these conditions it’s important to speak with your healthcare provider. They can help you undergo the proper testing methods for a diagnosis.

As previously discussed, other types of cortisol testing may be unreliable and expensive, and adrenal fatigue doesn’t appear to be a valid medical diagnosis. However, there are several underlying issues that may be at the root of your fatigue and can be easily addressed.

6 Common Triggers of Chronic Fatigue

There are many factors that may be contributing to your low energy levels. The following are just a few of the top chronic fatigue triggers that we see in our practice. 

1. Sleep Issues

Sleep disturbances often go hand-in-hand with hormonal imbalances (such as cortisol) [26, 27] and can be a significant contributor to chronic fatigue. Try prioritizing your sleep by getting eight to nine hours of sleep every night. Meditation, minimizing blue-light exposure prior to bed, and using a white-noise machine can all help to improve sleep quality. 

If you’re still experiencing sleep disturbances after improving your sleep hygiene, you may need to seek out a specialist to test you for sleep apnea. Sleep apnea is a common cause of excessive daytime sleepiness, and can be diagnosed with an overnight sleep study. 

Acupuncture and yoga have also been shown to improve sleep, especially in those with hormonal imbalances [28, 29], and are well-known to reduce stress levels and produce other positive health effects.

2. Chronic Stress 

When you undergo constant stress, it derails hormone production in the endocrine glands, such as the pituitary and adrenal glands [30]. Chronic stress is frequently attributed to external stressors, like work, family issues, and money insecurity. However, other common internal stressors include blood sugar swings, chronic inflammation, and chronic infections. 

Chronic stress can even lead to burnout and physical changes in the body, such as [31]:

• Disrupting the hypothalamic-pituitary-adrenal (HPA) axis — the pathway involved in cortisol production
• Reducing brain-derived neurotrophic factor (BDNF) — a hormone involved in cognition and memory
• Impairing your ability to create new neurons, known as neurogenesis
• Causing atrophy (shrinkage) in brain structures involved in mood regulation

Balancing stress levels with things like meditation, yoga, regular exercise, and therapy can be vital in overcoming chronic fatigue. 

3. Poor Gut Health

Chronic fatigue is often associated with chronic gut issues, like irritable bowel syndrome (IBS) and leaky gut syndrome [32, 33, 34, 35]. Gut disorders may not always present with specific GI symptoms, and can be a hidden cause of fatigue.

Dysbiosis (an overgrowth of gut bacteria), intestinal inflammation, and gut pathogens can all contribute to poor gut health, resulting in low energy levels. Fortunately, there are several things you can do to improve your gut health and get your energy levels back on track. 

Probiotic Supplements

Research shows that probiotics can help correct gut dysbiosis and inflammation [36], and reduce symptoms of anxiety and chronic fatigue [37]. Probiotic supplements may even lessen abnormally elevated cortisol levels [38].

We recommend Triple Probiotic Therapy, which supplements three different types of high-quality probiotics at once, for the best results. For more information on probiotics, please refer to our comprehensive probiotics starter guide. 

Dietary Changes 

An elimination diet that removes common food triggers can also be a great start to addressing poor gut health and chronic fatigue. We recommend beginning with the Paleo diet to see if it resolves your symptoms. This diet removes common food triggers like dairy, gluten-containing grains, and processed foods. It also emphasizes high-protein foods, increases healthy fats, and reduces carbohydrate intake. 

If you don’t notice an increase in energy levels or any associated gut symptoms in three to four weeks, it may be time to try a more specialized diet, like the low FODMAP diet. This diet is more restrictive, but can help correct specific underlying issues that may be contributing to your fatigue, such as gut dysbiosis [39, 40, 41].

It may take a while to find out which diet is right for you, as everyone has their own food triggers. We recommend sticking with each diet for three to four weeks before re-evaluating your energy levels and determining if it works for you. 

4. Thyroid Disorders

An underactive thyroid, known as hypothyroidism, is a common cause of low energy levels, and often accompanies other hormonal imbalances. Hypothyroidism commonly presents with symptoms of:

• Fatigue
• Sleep disturbances
• Dry skin, hair, and nails
• Weight gain
• Menstrual abnormalities
• Cold intolerance 

A functional medicine practitioner can evaluate your symptoms and run a few simple thyroid function tests to see if low thyroid hormones are at the root of your chronic fatigue. Depending on your results and other underlying conditions, correcting a thyroid imbalance may include supplements, healing the gut, and prescription medications. 

Keep in mind that hypothyroidism is often wrongly diagnosed and treated. While true hypothyroidism can certainly cause fatigue and does require treatment, many practitioners, particularly in the natural or functional medicine fields, erroneously prescribe thyroid hormones to those with subclinical hypothyroidism or “sluggish thyroid”. 

Highlighting what we see in the clinic virtually every week, a 2021 meta-analysis of 17 studies found that upwards of 30% of patients who were taking hypothyroid medication actually did not need it – they were able to discontinue their treatment and maintain normal thyroid levels [42]. Make sure to work with a trusted practitioner when it comes to determining your need for thyroid treatment, and if you’re not sure, it’s best to look for a second opinion. 

5. Blood Sugar Imbalance

Blood sugar swings often result in energy dips, as glucose is the body’s main source of energy. Eating small meals frequently throughout the day can help maintain blood sugar levels and improve fatigue. 

It’s important to eat low-glycemic foods in order to prevent blood sugar swings. Fortunately, the Paleo diet implements these foods and doesn’t require you to heavily restrict your food intake. Low-glycemic foods include:

• Leafy green vegetables
• Berries, such as blackberries, blueberries, and raspberries
• Lentils and beans
• High-quality fats like avocados, nuts and seeds, olive oil, and nut butters
• Healthy protein sources, including non-processed meats and freshwater fish

High glycemic foods, such as white bread, potatoes, cereals, and sugars can all spike blood sugar, creating a rebound effect of low blood glucose and fatigue several hours after eating. 

6. Nutrient Deficiencies

Several vitamin and mineral deficiencies are thought to contribute to low energy levels. Iron deficiency is a common cause of anemia in women, with fatigue as one of the major presenting symptoms [43].

Other symptoms include:

• Low blood pressure, dizziness, and fainting
• Cold hands and feet
• Hair loss and pale skin
• A low-functioning thyroid and other hormonal imbalances

If you suspect that iron deficiency may be at the root of your fatigue, consult with a practitioner prior to supplementing with iron, as too much can also lead to negative health effects. 

Vitamin B deficiencies, especially folate and B12, are another common cause of anemia and fatigue. B-complex supplements may help correct any deficiencies and reduce stress levels that could be contributing to your fatigue [44, 45].

Final Thoughts on the Dutch Test

The DUTCH test may be an accurate alternative to serum blood tests for evaluating hormone levels, but their more in-depth cortisol results can be difficult to apply clinically. Research shows that symptoms of chronic fatigue, and other potential signs of adrenal dysfunction, do not correlate with cortisol levels. 

We support treating the patient as an individual and treating their specific symptoms, rather than relying on a single test result for the answer to their health problems. There are many factors that may contribute to low energy levels, such as diet, stress, hormone imbalances, and nutrient deficiencies. 

If you’re looking for assistance in finding the root cause of your fatigue and 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 patients 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.