What is the difference between blood, urine and saliva cortisol testing?

What is the difference between blood, urine and saliva cortisol testing?

*This information is to be used for educational purposes only and is not intended to provide medical care or advice*

There are three forms of cortisol in the body:

1.Free cortisol

2.Bound cortisol

3.Cortisol metabolites

Bound Cortisol– Cortisol which is attached to a specific protein (CBG) is known as a bound cortisol. Metabolized cortisol evaluates how much cortisol is being made in total and cleared through the liver.

Free Cortisol- Cortisol which is not attached to any protein known as free cortisol. Free cortisol reveals how much cortisol is free to bind to receptors and allows for assessment of the circadian rhythm.

Cortisol metabolites– Metabolites of cortisol gives insight into the relative activity of 11b-HSD types I and II, which controls the activation and inactivation (to cortisone) of cortisol.

Approximately 90% of cortisol is bound to cortisol-binding globulin (CBG), also known as transcortin, and albumin.  Transcortin: corticosteroid-binding globulin (CBG) or serpin A6, is a protein encoded by the SERPINA6 gene and is an alpha-globulin. Albumin: main protein in your blood and carries substances such as hormones, vitamins, and enzymes throughout the body.

5% of circulating cortisol is free (unbound). Only free cortisol can access the enzyme transporters in the liver, kidney, and other tissues that mediate metabolic and excretory clearance.

Cortisol-binding globulin (CBG) has a low capacity and high affinity for cortisol, whereas albumin has a high capacity and low affinity for binding cortisol. Variations in CBG and serum albumin due to renal or liver disease may have a major impact on free cortisol.

Standard Ranges for Cortisol:

A normal adult range for cortisol levels in urine is between 3.5 and 45 micrograms per 24 hours.

Reference ranges for salivary cortisol assay: <0.4–3.6 nmol/L at 2300 h & 4.7–32.0 nmol/L at 0700 h.

Standard 8 a.m. range for blood serum cortisol is between 6 and 23 micrograms per deciliter (mcg/dL)

Measuring both free and bound cortisol levels allows for insight into the rate of cortisol clearance/metabolism and clearance.

Urine and saliva cortisol testing are used to evaluate free cortisol levels. Morning saliva cortisol panels are done to measure the diurnal cortisol curve. Blood cortisol testing is used to evaluate total cortisol and also bound cortisol.

In patients with adrenal insufficiency, an evaluation of cortisol tested via blood, saliva and urine can all be beneficial in evaluating the efficacy of their cortisol replacement medication(s). Recommended protocols are a comparative assay of cortisol levels from urine, blood and saliva specimens. The patient’s quality of life, symptomatic complaints and also fatigue levels should also be used when evaluating a proper cortisol dosing regimen.

Sources:

Abraham, S. B., Rubino, D., Sinaii, N., Ramsey, S., & Nieman, L. K. (2013). Cortisol, obesity and the metabolic syndrome: A cross-sectional study of obese subjects and review of the literature. Obesity (Silver Spring), 21(1), 1-24. doi:10.1002/oby.20083

Dhillo WS, Kong WM, Le Roux CW, Alaghband-Zadeh J, Jones J, Carter G, Mendoza N, Meeran K and O’Shea D. Cortisol-binding globulin is important in the interpretation of dynamic tests of the hypothalamic-pituitary-adrenal axis. Euro J Endo. 2002;146

Hoshiro, M., Ohno, Y., Masaki, H., Iwase, H., & Aoki, N. (2006). Comprehensive Study of Urinary Cortisol Metabolites in Hyperthyroid and Hypothyroid Patients. Clinical Endocrinology, 64, 37-45. doi:10.1111/j.1365-2265.2005.02412.x

Taniyama, M., Honma, K., & Ban, Y. (1993). Urinary Cortisol Metabolites in the Assessment of peripheral Thyroid Hormone Action for Diagnosis of Resistance to Thyroid Hormone. Thyroid, 3, 229-233.

Tomlinson, J. W., Finney, J., Hughes, B. A., Hughes, S. V., & Stewart, P. M. (June 2008). Reducing Glucocorticoid Production Rate, Decreased 5alpha-Reductase Activity, and Adipose Tissue Insulin Sensitization After Weight Loss. Diabetes, 57, 1536-1543.

Bancos I, Erickson D, Bryant S, et al: Performance of free versus total cortisol following cosyntropin stimulation testing in an outpatient setting. Endocr Pract 2015 Dec;21(12):1353-1363 doi: 10.4158/EP15820

Petersen KE: ACTH in normal children and children with pituitary and adrenal diseases. I. Measurement in plasma by radioimmunoassay-basal values. Acta Paediatr Scand 1981;70:341-345

Hamrahian AH, Oseni TS, Arafah BM: Measurements of serum free cortisol in critically ill patients. N Engl J Med 2004;350;16:1629-1638

Ho JT, Al-Musalhi H, Chapman MJ, et al: Septic shock and sepsis: a comparison of total and free plasma cortisol levels. J Clin Endocrinol Metab 2006;91:105-114

le Roux CW, Chapman GA, Kong WM, et al: Free cortisol index is better than serum total cortisol in determining hypothalamic-pituitary-adrenal status in patients undergoing surgery. J Clin Endocrinol Metab 2003;88:2045-2048

Huang W, Kalhorn TF, Baillie M, et al: Determination of free and total cortisol in plasma and urine by liquid chromatography-tandem mass spectrometry. Ther Drug Monit 2007;29(2):215-224

Mayo Clinic Laboratories-  https://www.mayocliniclabs.com/test-catalog/Clinical+and+Interpretive/65484

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Recently passed California bill harmful to pediatric adrenal disease sufferers

 

The SCR- 110 Sex Characteristics Bill is a bill California presented that was amended in the Senate on May 9 2018.

The context of the bill is coming from the wake of the gender queer and transgender issue. This bill prevents parents from making a decision on whether a child should be deemed male or female In those born with ambiguous genitalia.

Where this is concerning is there are genetic deformities and congenital diseases that are negatively impacted by this bill.

In these specific cases, this bill negatively impacts children born with diseases such as congenital adrenal hyperplasia. CAH is a life threatening disease which can cause children to be born with ambiguous genitalia, hormonal issues and requires life long steroid cortisol replacement medications.

Most pediatric endocrinologists agree that when CAH causes genetic abnormalities or genital mutation, these cases require medical intervention.

The danger of this bill is that these children will not receive the care that they need because of laws passed by politicians NOT educated informed physicians regarding medical care.

The concerning part is when decisions of parents and physicians are taken away by legislators who have no education regarding the dangers of improper medical treatment with diseases such as CAH.

It is understood, the concept of not wanting to cause someone to have gender dysphoria or to be forced to choose a gender; but in this case these specific medical issues need to be addressed.

This bill takes autonomy away from parents and physicians to make that choice.

Children, especially females born with CAH typically have ambiguous genitalia that needs to be corrected. These children can also suffer from hormonal issues such as polycystic ovarian syndrome.

This bill will inhibit the proper care of these children.

The treatment of CAH has nothing to do with gender identification.

Bills like this take the power of medical decisions out of parent’s and medical professional’s hands.

Below is a brief excerpt of the bill so you can fully understand the context.

This bill was amended by Senator Wiener, and is as follows-

This measure among other things called upon stakeholders in the health professions to protect children born with variations of sex characteristics.

Whereas between 1% and 2% of individuals born with variations of sex characteristics; which may include differences in genital anatomy from a hormonal variations or internal reproductive structure: Whereas intersex refers to the rare variety of physical indicators that indicate the differences which occur about the same frequency as do green eyes.

Whereas the majority of babies born with these variations are healthy and do not require medical or other interventions related to sex characteristics until puberty.

Beginning in the 1950’s physicians in the United States began performing irreversible surgery on intersex infants without medical justification and attempt to surgically or hormonally force them to conform to what the  physician perceived as a typical male and female body.

Source- https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180SCR110

So what can we do about it?

The Judiciary Committee phone number is (916) 319-2334.

It is imperative that we have representation from patients, family members and medical professionals to stop this bill.

This is not an attack on the gender-queer or transgender population, this is a protection for children born with a serious, life threatening, incurable disease.

 

This bill states- “California should serve as a model of competent and ethical medical care and has a compelling interest in protecting the physical and psychological well-being of minors.”

 

If that be the case, I urge Senator Wiener, Senator Glazer and Assembly Member Limón to reconsider this bill and amend it to protect children with CAH.

Please call and request an amendment to the SCR-110 Sex Characteristics Bill in favor of children born with CAH.