Blood draw
Extended Cortisol (Stress Hormone)
Cortisol, DHEA-S, testosterone, TSH, and fT4. Comprehensive hormone analysis for burnout and chronic stress.
€ 170,00
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Hormones · Blood
Cortisol/DHEA-S ratio
Ratio between two measured adrenal hormones; not a validated measure of stress or adrenal function.
At a glance
- Measured in blood
- In 1 test panel
- No special preparation
Explanation
Cortisol/DHEA-S ratio: what is measured?
This value is calculated by dividing the cortisol in the blood by the DHEA-S in the blood; both are measured in the same blood draw. Cortisol and DHEA-S are both made by the adrenal glands, controlled by ACTH from the pituitary gland. Cortisol has a strong daily rhythm and responds to illness and tension; DHEA-S fluctuates much less and falls with age. The ratio is sometimes explained as a balance between a 'stress hormone' and a 'recovery hormone', but that explanation is not scientifically supported.
What can it detect?
- Nothing on its own: no disease can be diagnosed with the ratio
- An abnormal ratio mainly shows that the cortisol or the DHEA-S itself is abnormal; those separate values determine the meaning
Result
What does the result mean?
Cortisol/DHEA-S ratio too high
A high ratio means that the cortisol is high relative to the DHEA-S. This is usually due to a high cortisol at the time of the blood draw: early in the morning, with tension, poor sleep, illness, heavy exercise or with use of the contraceptive pill, which raises the binding protein. It can also be due to a low DHEA-S, which is normal with aging. A high ratio does not prove chronic stress, burnout or 'adrenal fatigue'; for the meaning, a doctor looks at the separate values.
Cortisol/DHEA-S ratio too low
A low ratio means that the cortisol is low relative to the DHEA-S. This is often because the blood was drawn later in the day, or due to a relatively high DHEA-S, for example in young people, in women with PCOS or with use of DHEA supplements. Use of corticosteroids (such as prednisone) lowers both cortisol and DHEA-S. A low ratio is no proof of exhausted adrenal glands; with symptoms that fit a cortisol deficiency, a cortisol measurement early in the morning is the usual first step.
After an abnormal result
The GP assesses the separate values of cortisol and DHEA-S. With a low morning cortisol, a repeat measurement early in the morning follows, along with questions about corticosteroid use and, if needed, measurement of ACTH; with a high cortisol and symptoms of Cushing's, a targeted test follows, such as late-evening saliva cortisol or a dexamethasone suppression test. With stress symptoms without physical abnormalities, hormone testing is not the next step.
Reliability
How reliable is the test?
The ratio adds nothing beyond the separate values of cortisol and DHEA-S. It has not been shown that the ratio helps in diagnosing or treating a disease, and there are no generally accepted reference values. 'Adrenal fatigue' is not recognized as a condition in mainstream medicine: there is no scientific evidence that the adrenal glands run out due to ongoing stress, and there is no validated test for it. Moreover, a single cortisol value says nothing about stress: the cortisol of healthy people under a lot of tension is in the same range as that of relaxed people.
What can affect the result?
- Everything that affects cortisol also changes the ratio: the time of the blood draw, tension, lack of sleep, illness, heavy exercise, alcohol, the contraceptive pill and corticosteroids.
- DHEA-S depends strongly on age and sex, so the same ratio means something different in a young person than in an older person.
- The outcome depends on the laboratory's units and measurement methods; numbers from other sources cannot simply be compared.
- DHEA supplements and anabolic agents raise DHEA-S and thereby lower the ratio.
Who it is for
Who is the test useful for?
Useful for
There is no group in whom the ratio says more than the separate values of cortisol and DHEA-S. With symptoms that fit a cortisol deficiency, such as severe tiredness with weight loss, low blood pressure, nausea, salt craving and darker skin, or with symptoms that fit too much cortisol, the separate cortisol value and targeted follow-up testing are the right route. Not useful for measuring stress, burnout, tiredness or 'adrenal fatigue'.
How common is it?
There are no figures on an abnormal cortisol/DHEA-S ratio, because it is not a recognized condition. True adrenal diseases are rare: Addison's disease is estimated to occur in 40 to 115 per million inhabitants, and Cushing's syndrome due to a tumor is diagnosed in about 50 people per year in the Netherlands. The most common cause of a disturbed cortisol balance is the use of corticosteroids.
GP brochure on adrenal diseases (Dutch adrenal patient association NVACP) and Maastricht UMC+, Department of Endocrinology
Drawbacks and risks
- An 'abnormal' ratio can wrongly be seen as proof of adrenal fatigue or chronic stress and lead to expensive supplements or hormones, which can themselves harm your health.
- Because of the focus on a hormone ratio, a real cause of tiredness, such as an underactive thyroid, sleep apnea or depression, may be found later.
Get tested
Cortisol/DHEA-S ratio: test panels
Cortisol/DHEA-S ratio is part of these test panels. You order online and have your blood drawn at a collection point or collect the sample at home.
Evidence
Sources
This explanation is based on Dutch guidelines and independent information. It is general information, not a diagnosis. Discuss an abnormal result with your GP.
More about risks and results