Urinary Free Cortisol
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Urinary free cortisol measurements are used primarily in the diagnosis of hypercortisolism caused by Cushing syndrome. [1, 2, 3]
Reference ranges for urinary free cortisol vary by age, as follows:
Age 0-2 years – Not established
Age 3-8 years – 1.4-20 µg/24 h
Age 9-12 years – 2.6-37 µg/24 h
Age 13-17 years – 4-56 µg/24 h
Age 18 years or older – 3.5-45 µg/24 h
Cortisol: µg/24 h X 2.76 = nmol/24 h (molecular weight = 362.5)
Urinary free cortisol measurements are used primarily in the diagnosis of hypercortisolism caused by Cushing syndrome. [4, 5] Stress and exogenous glucocorticoid usage are other factors that can affect urinary free cortisol levels.
Using a cortisol-to-cortisone ratio, urinary free cortisol testing can also be used to diagnose inherited or acquired abnormalities of 11-beta-hydroxy steroid dehydrogenase such as pseudohyperaldosteronism, licorice consumption, and chewing tobacco use.
Albeit rarely, urinary free cortisol can also be used to diagnose adrenal insufficiency.
Collection details are as follows:
Container/tube – Plastic 10-mL urine tube
Specimen volume – 5 mL
Collection instructions – Collect urine for 24 hours; at the start of collection, 10 g of boric acid is added as preservative
Additional information – 24-Hour volume is required
The main adrenal glucocorticoid is cortisol, and it has a central role in the metabolism of glucose and in the body’s response to stress. Corticotropin regulates adrenal cortisol production. Corticotropin is synthesized in the pituitary gland in response to hypothalamic corticotropin-releasing hormone (CRH). In turn, the production of both CRH and corticotropin are inhibited by serum cortisol (negative feedback loop). The system self-regulates to control proper levels of cortisol production. These coordinated stimulatory and inhibitory connections between CRH, corticotropin, and cortisol are termed the hypothalamic-pituitary-adrenal (HPA) axis.
Most cortisol circulates bound to cortisol-binding globulin (CBG, also known as transcortin) and albumin. Elevated estrogen levels are the most common cause of increased CBG levels; therefore, higher levels of cortisol are found in women, during pregnancy, and in persons on estrogen therapy.
In normal circumstances, less than 5% of circulating cortisol is free (unbound). Free cortisol is the physiologically active form of cortisol and is filterable by the renal glomerulus. With increased levels of plasma cortisol, free cortisol levels increase, which is then filtered through the glomerulus.
The concentration of plasma free cortisol correlates well with urinary free cortisol. Urinary free cortisol values represent the excretion of the circulating, biologically active, unbound (free) cortisol. Urinary free cortisol is a sensitive test for the various types of adrenocortical dysfunction, particularly hypercortisolism (Cushing syndrome).
The primarily use for urinary free cortisol measurements is to diagnose hypercortisolism (states of excess cortisol); however, urinary free cortisol measurements are less helpful for diagnosing hypocortisolism (cortisol deficiency).
While hypercortisolism is uncommon, the signs and symptoms are common and include obesity, high blood pressure, and increased blood glucose concentration.
The cause of Cushing syndrome (endogenous hypercortisolism rather than exogenous hypercortisolism resulting from medication) is overproduction of cortisol due to either a primary adrenal disease (eg, adenoma, carcinoma, nodular hyperplasia) or an excess of corticotropin (from a pituitary tumor or an ectopic source). The most frequently diagnosed subtype of hypercortisolism is corticotropin-dependent Cushing disease resulting from a pituitary corticotroph adenoma. It most commonly occurs in women in the third to fifth decades of life. Insidious in onset, it usually occurs 2-5 years before a clinical diagnosis is made.
Elevated baseline urinary free cortisol levels can result from situations of acute stress (eg, hospitalization, surgery), from alcoholism, from depression, and as a side effect of many drugs (eg, exogenous cortisones, anticonvulsants).
Urinary free cortisol testing is not a reliable diagnostic tool for adrenal insufficiency.
Falsely low values can result from an incomplete urine collection or from renal disease with decreased renal clearance.
Cross-reactivity with some exogenous glucocorticoids (eg, prednisone) can occur, depending on the assay method (radioimmunoassay, high-performance liquid chromatography, or liquid chromatography–tandem mass spectrometry [LC-MS/MS]). The preferred assay is LC-MS/MS because it eliminates analytical interferences with substances such as carbamazepine (Tegretol) and synthetic corticosteroids that may affect immunoassay-based cortisol results. [3]
Pseudo-Cushing syndrome is increased production of cortisol without true clinical manifestations of hypercortisolism. It occurs in certain conditions, such as depression, alcoholism, anorexia nervosa, and pregnancy, among others. In such situations, HPA axis overactivity is similar to Cushing syndrome.
Findling JW, Raff H. Diagnosis and differential diagnosis of Cushing’s syndrome. Endocrinol Metab Clin North Am. 2001 Sep. 30(3):729-47. [Medline].
Boscaro M, Barzon L, Fallo F, Sonino N. Cushing’s syndrome. Lancet. 2001 Mar 10. 357(9258):783-91. [Medline].
Taylor RL, Machacek D, Singh RJ. Validation of a high-throughput liquid chromatography-tandem mass spectrometry method for urinary cortisol and cortisone. Clin Chem. 2002 Sep. 48(9):1511-9. [Medline].
Le Marc’hadour P, Muller M, Albarel F, Coulon AL, Morange I, Martinie M, et al. Postoperative follow-up of Cushing’s disease using cortisol, desmopressin and coupled dexamethasone-desmopressin tests: a head-to-head comparison. Clin Endocrinol (Oxf). 2015 Aug. 83 (2):216-22. [Medline].
Jung C, Greco S, Nguyen HH, Ho JT, Lewis JG, Torpy DJ, et al. Plasma, salivary and urinary cortisol levels following physiological and stress doses of hydrocortisone in normal volunteers. BMC Endocr Disord. 2014 Nov 26. 14:91. [Medline].
Carlos Solano Loran, MD Resident Physician, Department of Internal Medicine, Albert Einstein Medical Center
Carlos Solano Loran, MD is a member of the following medical societies: American College of Physicians
Disclosure: Nothing to disclose.
Nissa C Blocher, MD Attending Physician, Division of Endocrinology, Associate Program Director, Endocrinology Fellowship, Albert Einstein Medical Center
Nissa C Blocher, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American Medical Association, Endocrine Society, The Pituitary Society
Disclosure: Nothing to disclose.
Eric B Staros, MD Associate Professor of Pathology, St Louis University School of Medicine; Director of Clinical Laboratories, Director of Cytopathology, Department of Pathology, St Louis University Hospital
Eric B Staros, MD is a member of the following medical societies: American Medical Association, American Society for Clinical Pathology, College of American Pathologists, Association for Molecular Pathology
Disclosure: Nothing to disclose.
Urinary Free Cortisol
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