The Importance of Accurate Cortisol Testing to Understand Stress Levels

Apr 06, 2018

Submitted by the International Autoimmune Institute & Bingham Memorial Center for Functional Medicine



David J. Bilstrom, MD—the Director of the International Autoimmune Institute & Bingham Memorial Center for Functional Medicine—explores why accurate cortisol testing is important to understand how stress levels may be contributing to autoimmune disease.

What is cortisol?

Cortisol, often called the “stress hormone,” is a vitally important hormone that is necessary to eliminate inflammation in the body. Cortisol is made by the adrenal gland that sits on top of the kidneys.

“A good example of how cortisol reduces inflammation in your body is that cortisol turns into cortisone—a steroid hormone that your body makes naturally to get rid of inflammation,” Dr. Bilstrom says.

If somebody gets any benefit from using a steroid medication, whether it’s a steroid cream for a rash, a steroid nasal spray, a steroid for asthma, a steroid injection for a bad knee, or oral steroids, this always begs the question: “Why do they need a man-made steroid from the outside? Why are they not making enough steroids on the inside of their bodies to get rid of this inflammation on its own??

How is cortisol tested?

Ideally, cortisol should be the highest in the morning and slowly decrease throughout the day; hitting its low point late in the evening in order to fall asleep easy. However, that isn’t the case for many people.

“Often time’s cortisol is tested through a blood test and only tested in the morning,” Dr. Bilstrom says. “Knowing that it should be different at different times in the day means that just testing in the morning doesn’t give you enough information to understand what is going on.”

Cortisol tested with a 24-hour urine test helps to understand someone’s total cortisol production. These tests are effective at tracking the extremes of cortisol abnormality. When cortisol production is very low, this may indicate Addison’s disease, which is as a result of the adrenal gland not producing enough hormones. The opposite extreme is high levels of cortisol, resulting in Cushing’s disease, which can affect weight in many parts of the body.

“It should be noted that the average levels of someone’s cortisol levels over a 24-hour period of time may be deceiving,” Dr. Bilstrom says. “The average may look good, however, you may be totally low at the time of day when you’re supposed to be high (the morning) and very high when you’re supposed to be low (the evening).”

Why saliva testing?

A saliva cortisol test involves testing at four different times during one day in order to see what the stress hormone rhythm or lack of rhythm is. Saliva testing is also a much better indicator of what is happening inside of the cells compared with blood work. Blood work focuses on the liquid carrying the cell around, while saliva cortisol testing looks inside the cells.

“The worst time to check for a stress hormone level is right after you get stabbed with a sharp object; that’s basically what a blood draw is, stabbing you with a sharp needle and it’s going to alter the stress hormone level immediately,” Dr. Bilstrom says. “If we were to check somebody’s cortisol with a blood draw, they come in to see me and I say, ‘Oh by the way your saliva cortisol levels are quite high.’”

“They would say, “You just stabbed me with a sharp object, wouldn’t that alter my cortisol levels?”

“And I’d have to say, “Yes.” That’s another reason why it’s so much better to do the saliva cortisol, plus you don’t have to get stuck four times in a day.”

Stress in the body

The body doesn’t differentiate between different types of stress. To the body, stress is stress, whether it’s physical, emotional, or spiritual. It’s all just stress. Like a physical stress that occurs when someone twists their ankle. The body uses cortisol to manage the inflammation and take the pain away. When someone experiences too much stress, too often or too big of ones, they, can get stuck in stress mode. ‘Fight-or-flight’ or ‘life or death’ mode. The body is an excellent manager of all types of stress, but being stuck in a constant state of high stress interrupts the body’s ability to heal.

“Imagine you’re taking a nice walk and a bear jumps out and wants to eat you,” Dr. Bilstrom says. “What do you think your stress hormone will do? It’s going to jump up, but not like the everyday sprain my ankle or tough day at the office. It’s going to go way up. So when people’s cortisol levels get stuck way up there, it’s the same as if a bear was chasing them—life or death, fight or flight, 24-hours a day, seven days a week, month after month, year after year,. In the end, it’s how long can your body sustain high levels of cortisol, or how long you can run from a bear before your body just gives out?”

Health problems begin to develop when you’re stuck in stress mode because the body is spending so much time managing stress it can’t fix those health issues itself. To the body, the stress is now the most important factor, but it’s becoming destructive.

“When you get a cut and you don’t have an open wound for the rest of your life, that’s because the body fixes it,” Dr. Bilstrom says. “The body would be happy to fix all of these things itself, but we have to get rid of the bear first. And you can only run from the bear for so long. Eventually, you’ll get really tired and really sore and not able to do the things you need to do and you crash. People don’t feel well at constant, high levels of the stress hormone, but they feel even worse once the crash starts.”

In many cases, people whose bodies are managing at high levels of stress all of the time, they write off symptoms as:

  • Well that’s life.
  • My work is stressful.
  • Raising kids is stressful.
  • I don’t sleep so well anymore.
  • Maybe it’s my age.
  • Maybe its genetics.
  • This is how it’s supposed to feel given what my life is like.

“No,” Dr. Bilstrom says. “You should feel great no matter what.

How can you tell if someone is stuck in the stress mode?

In children, one thing that can happen is they have a hard time falling asleep and tend to stay up late. They may have nightmares. Other times this is characterized as a concentration problem or Attention Deficit Disorder (ADD). In adults, they will get a “second wind” late in the evenings and become night people, only getting their most restorative sleep in the morning between 7 a.m. and 10 a.m.

“This is what makes it difficult for these folks because they get their only restorative sleep when the world says they have to get up and go to school, they have to get up and get a job,” Dr. Bilstrom says. “They do not get the chance to get the only restorative sleep they might get all night long.”

When the “bear” first jumps out, and they are now stuck in the stress mode, it is understandable that concentration would be very high, but after a while there will ultimately be a loss of focus. With ADD and ADHD, we are seeing that loss of concentration and focus.

“That’s why many of the medicines children and adults are prescribed can be problematic. For example, Ritalin is basically an amphetamine (a stimulant) that just produces another bear to create yet another stress response,” Dr. Bilstrom says. “Yes, you concentrate better because there’s another bear chasing you, initially, but basically you’re just recreating the problem that got you there in the first place.”

Adults have a tendency to have trouble falling asleep and staying asleep, or they are “worriers,” which essentially means that person has always been stuck in the stress mode. Someone who is a worrier may tend to grind their teeth, bite their nails, or pick at their cuticles. This indicates that they are stuck in stress mode, which means their cortisol is off and they’ve got to get rid of that bear, otherwise it will be very difficult for the body to heal in any way.”

About David Bilstrom, MD



Taking the mind, body, and spirit into consideration, Dr. Bilstrom understands firsthand the benefits integrated medicine can provide to patients. He is triple board certified in Physical Medicine and Rehabilitation, Functional and Regenerative Medicine, and Medical Acupuncture. He has extensive experience in Anti-Aging & Regenerative Medicine, Acupuncture, Integrative Medicine, and Complementary and Alternative Medicines.

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