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Cortisol Metabolite Testing: Finding the Missing Link in Your Hormone Health
Episode 663rd May 2023 • ReInvent Healthcare • Dr. Ritamarie Loscalzo
00:00:00 00:15:06

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In this week’s episode of ReInvent Healthcare, we talk about a specific type of test that analyzes metabolites in the body. This test analyzes the levels of metabolites to help evaluate for adrenal dysfunction. 


The DUTCH (Dried Urine Test for Comprehensive Hormones) Test

There are different versions of the DUTCH test with different purposes that can check hormones, the cortisol awakening response, and adrenals, which in turn can find out about thyroid function. Another great thing about this test is it can also test for cortisol metabolites.

Cortisol Metabolites

Once cortisol is broken down by the liver for excretion, it is converted into cortisol metabolites. Each individual person has a different set of chemistry that may be contributing to their symptoms, fatigue, libido, etc. and looking into cortisol metabolites can go a long way in order to understand their dysfunctions better.

Cortisone and Cortisol

Cortisol is deactivated to cortisone and vice-versa through different types of enzymes. The ratio of cortisol to cortisone and their metabolites is something to look at to see how the body is excreting and this can show signs of inflammation and give us a better picture of how the adrenals are functioning.


Watch our recorded Thyroid Adrenal Workshop here.


 Welcome back to Reinvent Healthcare. I'm Dr. Ritamarie Loscalzo, and my mission is to empower a million or more people to go from disease and dysfunction to optimal health, and the best way to do that is by educating and empowering health practitioners. I passionately believe that just about every disease can be prevented or reversed.

If you are struggling with, or you have patients struggling with fatigue and adrenal dysfunction, and you want to understand what's going on at the level of cortisol metabolism so you can help support them to get better, today's episode is especially for you.

Before we get started, I want to remind you about the resource guide that we have for you all about adrenals. And if you go to, you're going to be able to download this guide with lots of great and helpful charts and herbs and testing and all that.

Today we're going to talk about testing. We're going to talk about the testing that we can do for adrenal dysfunction, and especially looking at some things that happen only in a test called the DUTCH test that I absolutely love.

We're looking at metabolites, not just looking at cortisol level. The conventional cortisol testing by Western medicine is to test somebody's cortisol in their blood in the morning and find out, “Do you have enough? Do you have too much? Do you have it just right?” What the DUTCH test does is it offers a different way of looking at it. It offers the ability to look at what's called the metabolites of cortisol and the ability to look at cortisol versus cortisone. By the end of this show, you are going to understand what that means and how to apply it with your clients and your patients, and if you're listening for yourself.

Metabolites are downstream of the main hormone. All hormones have metabolites. They get broken down by the liver and eliminated either in the urine or the stool. And when we look at those tests and we look at the metabolites, it gives us so much more information than just looking at cortisol in the blood in the morning.

In functional medicine, we typically look at saliva as a good place to look at hormones and especially cortisol, that can give us a pattern because we can test it throughout the day. It is a pattern of what levels of cortisol are being produced, but in saliva you can't see the metabolites. You can only see the metabolites in the urine.

When we look at this test and my favorite test combines saliva and urine, I love it because I can see so much more and I can get inferences about not just what's going on with adrenal function, not just what's going on with cortisol levels, but so much more in terms of thyroid and the gut and the liver and elimination and so on.

We're going to go into some detail here today. The things I like about testing for the adrenals are metabolites, being able to look at cortisol and cortisone, which is the inactive form of cortisol. I like being able to look at something called the cortisol awakening response, and we're going to go through that in detail in the next episode. And I love being able to look at DHEA, the hormone DHEA, which is super important, produced by the adrenals, and it's a precursor to testosterone, estrogen, all the different estrogens. This is an important thing to look at, but the testing that looks at DHEA-S, which is the inactive form and the DHEA, give us some more clues and more information.

There is an enzyme called sulfotransferase, the SULT2A1. If you do any genetic testing, you can look to see if somebody has a SNP and a variant in that enzyme to see if maybe they have some problems with deactivating, DHEA to DHEA-S or if they are having a problem with doing that too rapidly. This test will give you some clues there.

Let's take a look at cortisol versus cortisone. The kidney, the salivary glands, and the colon deactivate cortisol to cortisone by an enzyme called 11β-HSD1 in particular. Why would we want to deactivate cortisol? Well, we don't want unlimited amounts of cortisol in the system because it can raise blood pressure, it can raise blood sugar and so much more. The body has a natural balance between cortisol and cortisone. And so when the cortisol levels are higher than needed, we just convert it into cortisone. When more energy, more adrenal oomph, so to speak, is needed, we can convert it back and the liver and the fat cells can convert cortisone back into cortisol, and that's 11β-HSD2.

We need to look at, when we're looking at tests,to really see the picture of how the adrenals are functioning. The ratio of cortisol to cortisone and the best way to look at it is the metabolites of each of those. How is the body favoring excretion? The metabolites are measures of the cortisol or the cortisone, that is being set up for excretion, not how much is being produced, but how much is being set up to be excreted from the body.

And there's different ways to look at that. If the metabolites favor cortisol, in other words, we're eliminating more cortisol, it often indicates that there's a lot of reactivation of cortisone to cortisol, and it can be a sign of inflammation or someone might be taking licorice extract. Those are the questions you may want to ask. If you get this test result back and you see that the cortisol metabolites are much higher than the cortisone.

And if the metabolites favor cortisone, it often indicates that the body's trying to protect itself from the high levels of cortisol, from high blood pressure, from high blood sugar, and so much more. The body has this natural, you know, checks and balances, and we want to respect that. And in the typical testing for adrenals, Whether the medical testing of just looking at the blood first thing in the morning or the more naturopathic functional way of looking at saliva four or five times a day, those don't cut it all the way.

They don't give you the full picture, and when you can get the full picture, you're much better able to identify where the imbalances lie and what you need to do to help support somebody to get their health back.

Metabolites are the downstream versions that are slightly chemically altered versions of particular hormones that are getting set up to be eliminated. We have metabolites of estrogen, we have metabolites of cortisol. Those are the two that I look at the most. The cortisol is broken down into metabolites by the liver. Guess what? The liver does a lot of stuff for us in eliminating things that we no longer need. So there's an enzyme called 5α- or 5β-reductase.

The metabolites of cortisol are either ⍶- tetrahydrocortisol, which is abbreviated ⍶-THF on the report, or 𝜷-tetrahydrocortisol, 𝜷-THF, again, β-THF. For cortisone, it's called tetrahydrocortisone or THE. Notice that what this means is we've tacked on this prefix onto the word cortisol or cortisone, tetrahydra. What that means is that there's 4 hydrogens added on. It basically is an alteration, a slight alteration to the cortisol molecule. And it becomes this whole new thing and it gets eliminated. There's no mystery about metabolites.. It's just a variation on the chemical structure.

Let's talk about what value is it to look at metabolites? What can you learn from the metabolites that you can't learn from just looking at the circadian rhythm of cortisol production? Well, we have a situation where you look at the test and you may see that their cortisol is super high, and their metabolized cortisol is super high. What that basically means is that we have overactivity.

We're in that alarm state where people are producing way too much. We may have low free cortisol along with low metabolites, and guess what? That means that the system is drained a little bit. The low levels are starting to lose the ability to make cortisol. That's why it's that way. Now, in addition to low cortisol, the metabolites are favoring cortisol.

It's an indication that the levels are going low, but the body's just trying real hard to maintain it. It's trying really, really hard to keep the energy up, to keep the levels up so this person doesn't experience complete exhaustion. We're hanging on. In other words, if the metabolites favor cortisone, it means that the cortisol is being deactivated.

And that could be because we're trying to protect from the negative effects of elevated cortisol. See, you don't get this by just looking at cortisol. We have to do these metabolite testing, the urine testing for the metabolites. If we have high free cortisol and low metabolites or high free cortisol with high cortisone can mean a number of things.

It means that the metabolism is sluggish and the clearance is sluggish, that the body's not able to eliminate the excess cortisol, and so it's maintained in the system. What kind of things can be contributing to that? Well, hypothyroidism, who would've known you can do a DUTCH test for the adrenals and find out about thyroid function, really cool, or sluggish liver function, or anorexia.

You know, this person just doesn't have enough. of the nutrients and the foods coming in and their metabolism is slowing, slowing, slowing, slowing down. What about low free cortisol when it accompanies high metabolized or even normal or high normal metabolized? Well, that means that the clearance is elevated,

we're getting rid of a lot. We've got a little bit of cortisol that's being circulated to be able to be functional, but we're getting rid of a lot of it. Why? Why is that elevated clearance? Well, a lot of times it happens just because somebody's overweight, they're in a state of obesity, all that extra fat putting a strain on the system.

It could be hyperthyroidism, like the person is hyperthyroid, and we're eliminating, we're metabolizing and eliminating way too much. And here's the thing with hyperthyroidism. Most of the people I see personally are not hyperthyroid. They're hypothyroid. But many of them are on medication, and when people are overmedicated for thyroid, it comes across in the DUTCH as a hyperthyroid.

It may not even show on the thyroid labs yet, but if they're overmedicated, their cortisol is going to be low and they're going to have high metabolites. That might account for people who are being medicated and they're still tired. It could be because of this imbalance between the metabolites and the total.

Stress. long-term stress, guess what? Who's not under long-term stress? So it could be that. It could be that they're on steroids. But I'm telling you these because I want you to be asking the questions. When you get back that test, you're not just going to go, Oh, this is what's happening. Here's some adaptogen.”

You can be really looking and asking more questions if you haven't already asked them. Are they on thyroid medication? Which you should ask right at the beginning. But if you haven't, you ask them, “are you on thyroid medication?” “Well, yeah, I'm on thyroid medication.” “Well, this test indicates that you might be hyperthyroid, you might be taking too much of that thyroid.So go back to your doctor and talk to them about adjusting the dose.” “Well, I'm too tired. I'm tired because of that.” Yeah, because we are saying that we're elevated clearance and it's not going to necessarily relate to fatigue going away. And again, you're going to ask them all these questions about stress and if they're on steroids, another, but if you haven't asked them that already, when this test comes back, you want to make sure that you have.

This is in a nutshell how you want to read a test result that comes back, a DUTCH test result, and understand all the different interactions.

This should help you to see why it's important to look at metabolites, not just look at cortisol alone, look at cortisol, cortisone, the ratio between them, the metabolites, the ratio of the metabolites between cortisol and cortisone, and then ask the right questions. You're seeing a lot of individual people.

Each individual has a different set of biochemistry that's playing in and might be contributing to their symptoms, their fatigue, their low libido, their irritability, their anxiety, and this test can go a long way in helping you to understand it. Know that before you can just look at it without like looking up these symptoms, you know, and looking and comparing will take a long time,

You have to do hundreds of these before you get there. I like to keep a chart on my desk and be as I'm looking through there and go, oh yeah. I can quickly identify the patterns that this person is showing. After a while, when you've done a lot of these and you see a lot of these different patterns, it's going to help you to know where to ask the questions and how to address your recommendations for this person.

Testing adrenals is not just about, “Oh, the adrenals are off. Here's some adaptogens.” You have to look at What are you recommending for them? What is their lifestyle? What is their diet? What are their medications and how you can support them in getting their energy back.

Remember to download our free resource guide at, and for more in-depth information and resources for health practitioners, visit and become part of the movement to reinvent healthcare and until next time, shine on.