For patients who appear to have HPA axis dysfunction on DUTCH but findings are also consistent with hypothyroidism, you would ask to search for a cause for the hypothyroidism and address that too, right?

Okay, I think I can clear that up. On the DUTCH test, as you know, they report free cortisol and total cortisol separately, and that’s one of the reasons I like the DUTCH test over a lot of other options. When you see that free cortisol is high, but metabolized or total cortisol is low, that is often a sign of poor thyroid function. In fact, that ratio is actually being investigated as an early sign of thyroid dysfunction that often precedes the increase of MTSH or the drop in T4 and T3 that you would see with serum testing. In that case, the reason that we only treated the thyroid first is we suspected that that result of high free cortisol or metabolized cortisol was a result of thyroid dysfunction rather than HPA axis dysfunction. It’s not like that is mutually exclusive. You often see both in the same patient, but we wanted to treat the thyroid first and retest and see where their cortisol levels were. The reason for that, by the way, is that thyroid hormone is required to metabolize cortisol. If you have suboptimal levels of thyroid hormone and you get a buildup of free cortisol and you don’t have as much metabolized cortisol.