Cortisol (8:00 AM)

Immunity

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Cortisol plays a major role in Regulating metabolism, Managing immune response, Controlling blood pressure, Assisting in glucose regulation

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Cortisol (8:00 AM) - Comprehensive Medical Test Guide

Why is it done?
- Test Description: Measures cortisol levels during morning hours (8:00 AM), when cortisol naturally peaks due to circadian rhythm patterns.
- Primary Indications: Evaluation of suspected Cushing's syndrome (excessive cortisol production); assessment of pituitary and adrenal gland function; investigation of symptoms including hypertension, weight gain, muscle weakness, mood changes, and skin changes.
- Screening Purposes: Initial screening test for hypercortisolism due to its high sensitivity; evaluation of adrenal insufficiency; monitoring patients on corticosteroid therapy; assessment of HPA (hypothalamic-pituitary-adrenal) axis dysfunction.
- Typical Timing: Performed in early morning hours between 7:00-9:00 AM, preferably 8:00 AM, to capture peak cortisol levels when they are naturally at their highest before declining throughout the day.
Normal Range
- Reference Values (8:00 AM): 10-20 mcg/dL or 275-555 nmol/L (may vary slightly between laboratories)
- Units of Measurement: Micrograms per deciliter (mcg/dL) in the United States; nanomoles per liter (nmol/L) internationally
- Normal Results: Values within the established reference range indicate normal HPA axis function and appropriate cortisol production; excludes Cushing's syndrome in most cases when used as screening test
- High/Abnormal Results: Values >20 mcg/dL or >555 nmol/L suggest possible Cushing's syndrome, pituitary tumors, adrenal tumors, or other causes of excess cortisol production
- Low/Abnormal Results: Values <10 mcg/dL or <275 nmol/L may indicate adrenal insufficiency (Addison's disease), secondary adrenal insufficiency, or pituitary dysfunction
- Borderline Values: Values in the upper-normal range (16-20 mcg/dL) may require additional testing such as 24-hour urine cortisol or late-night salivary cortisol for confirmation
Interpretation
- Elevated Cortisol (>20 mcg/dL): May indicate Cushing's syndrome, pituitary adenoma (Cushing's disease), adrenocortical carcinoma, ectopic ACTH production (lung cancer, pancreatic tumors), or prolonged stress response. Further diagnostic evaluation needed to determine etiology.
- Low Cortisol (<10 mcg/dL): Suggests primary adrenal insufficiency (Addison's disease), secondary adrenal insufficiency (pituitary/hypothalamic dysfunction), or tertiary adrenal insufficiency. Requires ACTH stimulation testing and additional evaluation.
- Normal Range (10-20 mcg/dL): Generally excludes Cushing's syndrome with high sensitivity; however, does not completely rule out mild cases or cyclic Cushing's syndrome. May need additional testing depending on clinical suspicion.
- Factors Affecting Results: Acute stress, chronic stress, depression, anxiety, sleep disorders, obesity, estrogen therapy, corticosteroid medications, illness, time of collection (circadian rhythm variation), pregnancy, recent surgery, trauma, or infections can all affect cortisol levels.
- Sensitivity and Specificity: 8:00 AM cortisol has approximately 96-98% sensitivity for excluding Cushing's syndrome when normal, but moderate specificity; many causes can elevate morning cortisol beyond hypercortisolism.
- Clinical Significance: Loss of normal circadian cortisol rhythm (elevated morning levels that don't suppress) is more significant than a single elevated value; persistent elevation warrants confirmatory testing with 24-hour urine cortisol or low-dose dexamethasone suppression test.
Associated Organs
- Primary Organ Systems: Hypothalamic-pituitary-adrenal (HPA) axis including the hypothalamus, anterior pituitary gland, and adrenal cortex (zona fasciculata); also reflects nervous and endocrine system function.
- Conditions Associated with High Cortisol: Cushing's syndrome (pituitary adenoma, adrenocortical carcinoma), ectopic ACTH syndrome (small cell lung cancer), adrenal tumors, pituitary tumors, depression, anxiety disorders, eating disorders, metabolic syndrome, polycystic ovary syndrome (PCOS), hypertension, osteoporosis.
- Conditions Associated with Low Cortisol: Primary adrenal insufficiency (Addison's disease), autoimmune adrenalitis, tuberculosis of adrenal glands, adrenal hemorrhage, adrenoleukodystrophy, secondary adrenal insufficiency (pituitary tumors, hypopituitarism), tertiary adrenal insufficiency (hypothalamic disorders).
- Complications of Abnormal Cortisol: High cortisol: hypertension, diabetes, metabolic bone disease (osteoporosis/fractures), muscle wasting, immunosuppression (increased infections), psychiatric symptoms, cardiovascular complications, stroke risk. Low cortisol: cardiovascular instability, hypoglycemia, electrolyte abnormalities, life-threatening adrenal crisis.
- Multi-System Effects: Cortisol affects cardiovascular, metabolic, immune, bone, muscle, and psychiatric systems; dysregulation can cause multi-organ dysfunction and significant morbidity if untreated.
Follow-up Tests
- For Elevated Cortisol: 24-hour urine free cortisol (confirmatory test); Late-night salivary cortisol; Low-dose dexamethasone suppression test (LDST); ACTH level (to differentiate pituitary from adrenal or ectopic sources); High-dose dexamethasone suppression test (HDST); Pituitary MRI (if ACTH-dependent Cushing's suspected); Adrenal CT imaging; Insulin-like growth factor-1 (IGF-1) level; Thyroid function tests.
- For Low Cortisol: ACTH level (elevated in primary, low in secondary insufficiency); ACTH stimulation test (short cosyntropin test); Insulin tolerance test; Pituitary hormone panel (TSH, prolactin, growth hormone); Pituitary MRI; Adrenal CT/ultrasound; 21-hydroxylase antibodies (for autoimmune adrenalitis); Tuberculin skin test or IGRA.
- Monitoring Frequency: For diagnosed Cushing's syndrome: periodic testing during treatment (typically monthly initially, then every 3-6 months); For adrenal insufficiency: monitoring on replacement therapy (every 6-12 months or after dose adjustments); During acute illness or stress: more frequent monitoring may be needed.
- Related Complementary Tests: Midnight cortisol; Urinary cortisol metabolites; 11-beta-hydroxysteroid dehydrogenase inhibitor testing; Renin and aldosterone levels; Sodium and potassium levels; Glucose and lipid panels; Bone density scan (DEXA); Blood pressure monitoring.
Fasting Required?
- Fasting Status: NO - Fasting is not required for cortisol testing.
- Timing Requirements: Sample must be collected between 7:00-9:00 AM (preferably 8:00 AM) when cortisol is at its peak; later collection times will give artificially lower values due to circadian variation and should not be used for diagnostic purposes.
- Medications to Avoid: Corticosteroids (prednisone, dexamethasone, methylprednisolone) should be discontinued at least 24-48 hours prior to testing if possible (consult physician first); Birth control pills and estrogen therapy may increase cortisol-binding globulin and affect results - inform laboratory; Avoid medications if possible, but do not discontinue critical medications without medical advice.
- Patient Preparation Requirements: Patient should be rested and seated for at least 5 minutes before blood draw; Avoid strenuous exercise for 24 hours before testing; Minimize stress and anxiety on day of testing (stress elevates cortisol); Avoid caffeine intake on morning of test; Blood collection should be performed in outpatient clinic, not hospital setting to minimize stress-related elevation; Patient should be awake for at least 30 minutes before collection; Inform laboratory of any acute illness, surgery, recent trauma, or depression as these affect results.
- Special Considerations: Shift workers may have altered circadian rhythms requiring special interpretation; Pregnancy may increase results; Obesity can elevate cortisol; Recent hospitalization or acute illness can cause elevation; Sleep deprivation increases cortisol; If results are borderline or unexpected, repeat testing may be recommended on different day.

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