Salivary cortisone to estimate cortisol exposure and sampling frequency required based on serum cortisol measurements
Open accessAbstract
Context: Population studies frequently measure cortisol as a marker of stress, and excess cortisol is associated with increased mortality. Cortisol has a circadian rhythm, and frequent blood sampling is impractical to assess cortisol exposure. We investigated measuring salivary cortisone and examined the sampling frequency required to determine cortisol exposure. Methods: Serum and saliva with cortisol and cortisone were measured by liquid chromatography-tandem mass spectrometry in independent cohorts. The relationship between serum cortisol and salivary cortisone was analyzed in cohort 1 using a linear mixed effects model. The resulting fixed effects component was applied to cohort 2. Saliva cannot easily be collected when a patient is sleeping, so we determined the minimum sampling required to estimate cortisol exposure [estimated area under the curve (eAUC)] using 24-hour cortisol profiles (AUC24) and calculated the relative error (RE) for eAUC. Results: More than 90% of variability in salivary cortisone could be accounted for by change in serum cortisol. A single serum cortisol measurement was a poor estimate of AUC24, especially in the morning or last thing at night (RE >68%); however, three equally spaced samples gave a median RE of 0% (interquartile range, -15.6% to 15.1%). In patients with adrenal incidentalomas, eAUC based on three serum cortisol samples showed a difference between those with autonomous cortisol secretion and those without (P = 0.03). Interpretation: Accepting that most people sleep 7 to 8 hours, ∼8-hourly salivary cortisone measurements provide a noninvasive method of estimating 24-hour cortisol exposure for population studies.
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Three salivary cortisone samples collected at 8-hour intervals reliably estimated 24-hour serum cortisol exposure in a study of 50 participants including healthy volunteers and patients with MACS.
“In a study of 50 participants, including healthy volunteers and patients with MACS, they found that 3 salivary cortisone samples collected at 8-hour intervals reliably estimated 24-hour serum cortisol exposure.”
From Measuring cortisol in Cushing syndrome: diagnosis, monitoring, and cortisol circadian rhythm improvement. (2026) · cites this paper as [122]
The Discussion (page unavailable) says three approximately 8-hourly salivary cortisone measurements can give a good estimate of serum cortisol exposure. But Patients and Methods lists 14, 20, and 28 participants across the three cohorts—62, not 50—and says only the first two cohorts had salivary cortisone measurements. The three-sample approach is presented as a supported estimate, not as a result demonstrated in 50 participants using three collected saliva samples. (LLM, conf=0.88)
Experimental — accuracy not yet measuredDetecting subtle cortisol abnormalities through frequent blood sampling is unfeasible in patients with mild CS or MACS because samples must be collected in a clinic or hospital setting, making the process burdensome and disruptive.
“Detecting such subtle abnormalities through frequent blood sampling is unfeasible in this population, as samples must be collected in a clinic or hospital setting, making the process burdensome and disruptive for patients (122).”
From Measuring cortisol in Cushing syndrome: diagnosis, monitoring, and cortisol circadian rhythm improvement. (2026) · cites this paper as [122]
The Abstract (Context) says frequent blood sampling is impractical for assessing cortisol exposure, and the Abstract (Interpretation) notes that serum sampling requires venepuncture, unlike saliva sampling that can be done at home or work. The Discussion includes patients with adrenal incidentalomas and excess cortisol secretion, but the paper does not say blood samples must be collected in a clinic or hospital or establish that frequent sampling is unfeasible specifically for patients with mild CS or MACS. (LLM, conf=0.86)
Experimental — accuracy not yet measuredWhen measured by LC-MS/MS, salivary cortisone can be used in place of salivary cortisol for late-night screening for CS, particularly where contamination from exogenous glucocorticoids is a concern.
“When measured by LC-MS/MS, salivary cortisone can be used in place of salivary cortisol for late-night screening for CS, particularly in situations where contamination from exogenous glucocorticoids is a concern (122, 124).”
From Measuring cortisol in Cushing syndrome: diagnosis, monitoring, and cortisol circadian rhythm improvement. (2026) · cites this paper as [122]
The Methods describe LC-MS/MS measurement of salivary cortisone, and the Discussion reports that an 11:00 pm measurement differentiated functioning from nonfunctioning adrenal incidentalomas. The paper does not establish salivary cortisone as a replacement for late-night salivary cortisol in Cushing syndrome screening. Its Interpretation says cortisone is unaffected by oral hydrocortisone administration, but does not address contamination from exogenous glucocorticoids generally. No page numbers were available in our copy. (LLM, conf=0.86)
Experimental — accuracy not yet measuredSalivary measurements are non-invasive, can be collected with minimal stress in home or workplace settings, and are highly stable.
“The authors emphasize the advantages of salivary measurements, noting that they are non-invasive, can be collected with minimal stress in home or workplace settings, and are highly stable.”
From Measuring cortisol in Cushing syndrome: diagnosis, monitoring, and cortisol circadian rhythm improvement. (2026) · cites this paper as [122]
In newly diagnosed Cushing's disease, fluctuations rarely impair the diagnostic ability of LNSC, whereas in patients with recurrent or persistent disease after pituitary surgery, LNSC was frequently within the reference range, with the potential to cause false-negative results.
“In newly diagnosed CD this seems to only rarely impair the diagnostic ability of LNSC, whereas in patients with recurrent or persistent disease after pituitary surgery, LNSC was frequently within the reference range, with the potential to cause false-negative results (20).”
From Late-night salivary cortisol and cortisone should be the initial screening test for cushing's syndrome (2022) · cites this paper as [20]
Recently published data show that with upper reference limits of salivary cortisol 3.6 nmol/L and cortisone 13.5 nmol/L, the sensitivities and specificities of LNSC were 90% and 96%, and for LNS cortisone 100% and 95%, respectively.
“Recently published data show that when an 23 h upper reference limit of salivary cortisol and cortisone of 3.6 nmol/L and 13.5 nmol/L were used, the sensitivities and specificities of LNSC were 90 and 96%, and for LNS cortisone 100 and 95%, respectively (20).”
From Late-night salivary cortisol and cortisone should be the initial screening test for cushing's syndrome (2022) · cites this paper as [20]
Sandouk et al. demonstrated that there can be significant fluctuations in salivary cortisol levels in Cushing's disease.
“Sandouk et al. demonstrated that there can be significant fluctuations in salivary cortisol levels in CD.”
From Late-night salivary cortisol and cortisone should be the initial screening test for cushing's syndrome (2022) · cites this paper as [20]
Presence of HSD11B2 in the parotid gland makes salivary cortisone a useful marker for serum free cortisol and adrenal stimulation.
“the presence of HSD11B2 in the parotid gland makes salivary cortisone a useful marker for serum free cortisol and adrenal stimulation [[211], [212], [213]].”
From Human steroid biosynthesis, metabolism and excretion are differentially reflected by serum and urine steroid metabolomes: a comprehensive review (2019) · cites this paper as [213]
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- Authors
- Harrison, R. F., Debono, M., Whitaker, M. J., Keevil, B. G., Newell-Price, J., & Ross, R. J.
- Affiliations
- University of Sheffield (GB)
- Manchester Academic Health Science Centre (GB)
- Corresponding author
- Ross, Richard J
- ORCID
- Venue
- The Journal of Clinical Endocrinology & Metabolism
- Publisher
- The Endocrine Society
- Published
- 2018-10-03
- Volume
- 104
- Issue
- 3
- Pages
- 765-772
- ISSN
- 0021-972X (ISSN-L)
- 1945-7197
- PMC
- PMC6349003
- OpenAlex
- W2895454906
- Cited by
- 27
- References
- 31
- Citations by year
- 2026: 4 · 2025: 2 · 2024: 6 · 2023: 4 · 2022: 4 · 2021: 1 · 2020: 4 · 2019: 2
- FWCI
- 1.01
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- The Journal of Clinical Endocrinology & Metabolism (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
- Funders
- Seventh Framework Programme (281654)
- Topics
- Life Sciences › Neuroscience › Behavioral Neuroscience › Stress Responses and Cortisol
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Adrenal Hormones and Disorders
- Health Sciences › Medicine › Physiology › Clinical Laboratory Practices and Quality Control
- Keywords
- salivary cortisone, serum cortisol, sampling frequency, circadian rhythm, area under the curve, adrenal incidentaloma, autonomous cortisol secretion, stress biomarkers, non-invasive biomarkers
- MeSH terms
- Adolescent, Adrenal Gland Neoplasms, Adult, Aged, Circadian Rhythm, Cortisone, Female, Humans, Hydrocortisone, Male, Middle Aged, Retrospective Studies, Saliva, Time Factors, Area Under Curve, Young Adult, Healthy Volunteers
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