Dr. Amy Nett: I think some of this is, you also have to put it into the clinical context. Because as Chris mentioned, when we look at those four different categories of cortisol metabolites and then free cortisol, some of them are concordant, some of them are discordant. And some of them are due to disease states like inflammation, chronic stress, supplementation with licorice. But some of them are just due to normal physiologic states like being really well-rested.
So in terms of whether to treat it, sometimes you need to put it in the clinical context. We do have a unit where we talk more about the specific treatment. But some of what we’re looking at, so you’re saying when the test is telling if a patient has high or low cortisol metabolites compared to free cortisol, what is that information? How I use that information is if I have a patient who has high total cortisol, that’s telling me how much stress is their body perceiving. What is their hypothalamus perceiving in terms of stress? Are they experiencing or somehow perceiving? Because all our patients would say no, no, I’m not really stressed. I’m fine. Life is mellow, no big deal. But their total cortisol production is really high. So to me, that’s okay. There are actually some stress issues. Remember they can be internal, metals, dysbiosis, all of this stuff, internal sources of stress.
They can be external: not sleeping enough, eating foods that trigger you, something like that. So the cortisol metabolites tell me overall how much stress is this hypothalamus perceiving in a way. And then I look at the free cortisol and cortisone. So then they want to say, well, do they have relatively, you have to compare it to the total, which is where it gets tricky. But let’s say they have high total cortisol production, but low free cortisol. So high total but low free. Well then they’re rapidly metabolizing. So if somebody’s really rapidly metabolizing, then I’m going to think about, wait what do I need to think about here? Oh, I need to think about high insulin, hyperthyroidism, maybe obesity, but I need to think about why might they have this rapid metabolism.
And here, what we’re saying is, it’s helpful because if you were to do a saliva test, so again, the example I’m using is high total cortisol production, so the high metabolites, but low free cortisol. If we did just a saliva test, we’d be like, oh, no, they have really low cortisol production. We should give them adrenal glandulars and supplements to increase their cortisol production. But that’s not what they need. They actually need to decrease that metabolism so that the free cortisol stays around longer. So that’s the benefit. That’s what we’re looking at in terms of understanding cortisol metabolites in relation to free cortisol.
Similarly take the opposite example of the discordant case where you would have low cortisol metabolites, so low total cortisol production, but high free cortisol. So in that case the patient is a very slow metabolizer, very sluggish, sluggish cortisol metabolism. So again, if you looked at it on a saliva test, you would say, whoa, they have really high free cortisol. But if you know the metabolites, then you’re seeing, oh, wait, they’re actually putting out really low total cortisol. It’s just that they’re not metabolizing it. So again, it’s another clue, like wait, what do I need to think about? They have really sluggish metabolism. So think about hypothyroidism, low thyroid function, poor liver function; anorexia is another case that we can see this really sluggish metabolism.
So there’s more value. It’s understanding both the cortisol metabolites and the free cortisol. It just gives you a more complete understanding in terms of what’s going on with that person. Because knowing only one or the other doesn’t tell you. In terms of whether or not treatment is needed, you probably really need to get into what do their symptoms look like and address it from that more complete picture, and we’ll talk about treatment options more.