What tests can be used to diagnose hypercortisolism?

It is recommended that all patients who present with an adrenal adenoma be screened for hypercortisolism. After ruling out hypercortisolism due to exogenous cortisol exposure, there are 3 biochemical tests that can be used to screen patients for endogenous hypercortisolism.1-3
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Screening considerations

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Understanding the different cortisol tests3,5

Below are the most common screening tests.

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1-mg overnight dexamethasone suppression test

The dexamethasone suppression test (DST) detects autonomous cortisol secretion

Detects autonomous cortisol secretion

Abnormal range: >1.8 μg/dL

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Late-night salivary cortisol

Late-night salivary cortisol (LNSC) measures free cortisol in the saliva when cortisol should be at its lowest level

Detects the loss of diurnal rhythm

Abnormal range: >0.145 μg/dL

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Urinary-free cortisol

Urinary-free cortisol (UFC) measures excretion of circulating unbound cortisol in the urine over a 24-hour period

Detects the gross overproduction of cortisol over a period of time

Abnormal range: Exceeds the upper limit of normal for the assay3,5


The Endocrine Society Practice Guidelines suggest using the 1-mg DST or the LNSC in patients suspected of having less severe hypercortisolism.3

The American Association of Clinical Endocrinologists and American College of Endocrinology (AACE/ACE) Disease State Clinical Review suggests that the LNSC test seems to be the best choice as an early predictor of Cushing Disease recurrence.6

The American Association of Endocrine Surgeons (AACE/AAES) Medical Guidelines suggest that UFC is not an ideal marker for making a diagnosis of less severe hypercortisolism.7

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Management & Treatment