Comprehensive Adrenal Function Profile
The Comprehensive Adrenal Function Profile measures free cortisol at multiple timed intervals and DHEA in saliva to map the diurnal HPA axis curve. It is a functional-medicine tool used to assess cortisol awakening response, circadian rhythm, and cortisol:DHEA balance in patients with chronic stress, fatigue, or sleep disturbance, and is not a replacement for formal endocrine testing.
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Biomarkers
Saliva
Sample
10–14 business days
Turnaround
No, but avoid food, drink (except water), caffeine, and toothbrushing 30 minutes before each sample
Fasting
What is the Adrenal Function Profile test?
The Comprehensive Adrenal Function Profile uses multiple timed saliva samples to map the diurnal cortisol curve and assess adrenal androgen reserve. It is ordered by practitioners working in functional and integrative medicine to investigate suspected HPA axis dysregulation — broadly termed 'adrenal dysfunction' — in patients with unexplained fatigue, poor stress tolerance, sleep disturbance, or mood symptoms that do not fit classical endocrine disease. Salivary cortisol reflects the free, bioactive hormone and is particularly suited to capturing circadian rhythm, which is disrupted earlier and more sensitively than basal serum cortisol in chronic stress states. The profile is not a replacement for formal endocrine testing — it does not diagnose Addison disease or Cushing syndrome — but it provides a functional snapshot of HPA axis dynamics and is used to guide stress management, lifestyle, and nutritional interventions in a wellness or functional-medicine context.
What does the Adrenal Function Profile test measure?
Free cortisol in saliva reflects the unbound bioactive fraction and tracks the sharp rise within 30–45 minutes after waking, known as the cortisol awakening response. This peak is driven by hypothalamic-pituitary-adrenal axis activation and is sensitive to chronic stress, sleep quality, and circadian regulation.
The morning sample captures peak diurnal cortisol and is the most sensitive time point for detecting blunted awakening responses seen in chronic stress, burnout, and post-traumatic stress disorder. A normal morning surge supports intact HPA axis reactivity.
Mid-day salivary cortisol represents the declining limb of the diurnal curve, approximately halfway between the morning peak and evening nadir. It reflects the HPA axis transition from peak activity to basal regulation.
A persistently elevated noon value may indicate ongoing stress activation or incomplete diurnal decline, while a very low value in the context of a flat curve suggests adrenal underfunction or HPA axis dysregulation.
Evening cortisol reflects the diurnal nadir, when the HPA axis is quiescent and melatonin secretion begins. Free cortisol in saliva is particularly useful for detecting pathological elevations at this time point.
Elevated evening cortisol disrupts sleep onset and is a hallmark of chronic stress, insomnia, and Cushing syndrome screening. A blunted decline or elevated evening value indicates loss of normal circadian rhythm.
Late-evening or bedtime cortisol is the lowest point of the circadian cycle. Measurement of free cortisol in saliva at this time is recommended by endocrine guidelines as a screening tool for hypercortisolism.
Persistently elevated night cortisol is one of the first-line tests for suspected Cushing syndrome and is highly sensitive to circadian disruption from shift work, chronic stress, or mood disorders. It also correlates with poor sleep quality and metabolic dysregulation.
Dehydroepiandrosterone is an adrenal androgen precursor secreted in parallel with cortisol but with a flatter diurnal curve. Salivary DHEA reflects the free, unbound fraction and is used as a marker of adrenal reserve and anabolic balance.
DHEA is interpreted in relation to cortisol to assess the cortisol:DHEA ratio, a functional marker of HPA axis balance. Low DHEA with high cortisol suggests chronic stress and anabolic deficit; low DHEA with low cortisol may indicate adrenal exhaustion, though this concept is contested.
The cortisol awakening response is the dynamic rise in cortisol within the first 30–45 minutes after waking, distinct from the underlying diurnal rhythm. It is calculated as the difference or percentage increase between the waking sample and a post-awakening sample.
A blunted or absent CAR is associated with chronic stress, burnout, depression, and post-traumatic stress disorder. An exaggerated CAR may be seen in anticipatory stress or anxiety disorders. It is a sensitive functional marker of HPA axis reactivity.
The diurnal cortisol slope quantifies the rate of decline from morning peak to evening nadir. A steep slope reflects intact circadian regulation; a flat curve indicates loss of normal diurnal variation.
Flattened diurnal slopes are associated with chronic stress, metabolic syndrome, cardiovascular risk, insomnia, and all-cause mortality in research cohorts. They are interpreted as a marker of HPA axis dysregulation and allostatic load.
Why is the Adrenal Function Profile test ordered?
- Investigation of unexplained chronic fatigue, burnout, or post-exertional malaise not explained by thyroid, anaemia, or other routine tests
- Assessment of suspected HPA axis dysregulation in patients with insomnia, non-restorative sleep, or difficulty waking
- Evaluation of mood symptoms — anxiety, depression, irritability — where stress and circadian disruption may be contributing factors
- Monitoring of patients with fibromyalgia, chronic fatigue syndrome, or post-traumatic stress disorder, where HPA axis abnormalities are documented in research
- Screening for loss of diurnal cortisol rhythm in shift workers, caregivers, or individuals with high allostatic load
- Functional-medicine assessment of cortisol:DHEA balance before and after stress-reduction, adaptogen, or adrenal-support interventions
- Screening for elevated evening cortisol in patients with unexplained weight gain, central adiposity, or metabolic syndrome features, as an adjunct to formal Cushing workup if clinical suspicion is high
- Evaluation of athletes or high-performers with signs of overtraining, poor recovery, or relative energy deficiency
Sample collection and turnaround
Sample type
Saliva
Fasting required
No, but avoid food, drink (except water), caffeine, and toothbrushing 30 minutes before each sample
Collection method
At-home collection kit
Turnaround
10–14 business days
Collection notes
Patient collects saliva at four timed intervals: immediately upon waking (before rising), mid-day (around noon), early evening (between 4–6 PM), and before bed (around 10–11 PM). Samples are collected by passive drool into provided tubes. Timing adherence is critical; patients should record exact collection times. Kit includes instructions, collection tubes, and a prepaid return mailer. Samples are stable at room temperature for shipping.
Specimen requirements
Saliva collected by passive drool, minimum 1–2 mL per time point. Avoid contamination with blood from gum disease; patients with active oral bleeding should defer testing. Record medications, supplements, and timing on the requisition form.
What can affect Adrenal Function Profile results?
Cortisol is highly time-dependent; samples collected off-schedule invalidate the diurnal curve. Patients must collect immediately upon waking (before getting out of bed), at specified mid-day and evening times, and before sleep, with no eating, drinking (except water), or toothbrushing 30 minutes before collection.
Oral, inhaled, or topical corticosteroids suppress endogenous cortisol; oestrogen-containing contraceptives raise cortisol-binding globulin and may alter free cortisol. Discuss timing with the laboratory; some sources recommend stopping contraceptives for a cycle, though this is not always feasible.
Acute stress activates the HPA axis and cortisol rises appropriately; testing during acute illness does not reflect baseline adrenal function and should be deferred until recovery.
Circadian disruption alters the diurnal curve; results may reflect jet lag or shift-work disorder rather than chronic HPA dysregulation. Schedule testing during stable routine.
Eating and stimulants transiently raise cortisol; collection instructions specify avoiding food and caffeine 30–60 minutes before sampling to prevent spurious elevations.
Glycyrrhizinic acid inhibits 11β-hydroxysteroid dehydrogenase type 2, raising cortisol; patients taking liquorice-containing supplements or teas should discontinue them before testing.
What do Adrenal Function Profile results mean?
Elevated
Persistently elevated cortisol — particularly at evening or night — indicates chronic stress activation, insomnia-related HPA dysregulation, or, if marked and consistent across all time points, possible hypercortisolism requiring formal endocrine workup. An exaggerated cortisol awakening response may reflect anticipatory stress or anxiety. Elevated cortisol with low DHEA suggests an imbalanced stress response with anabolic deficit, a pattern often cited in functional medicine as 'hyperadaptation' or early-stage adrenal stress.
Normal
A normal diurnal curve — high morning cortisol with a robust awakening response, gradual decline through the day, and suppressed evening and night values — supports intact HPA axis function and circadian regulation. A balanced cortisol:DHEA ratio further suggests adequate adrenal reserve. Normal results do not exclude other causes of fatigue or stress-related symptoms.
Reduced
Low or blunted cortisol across the curve — especially a flat or absent awakening response — is interpreted in functional medicine as 'adrenal exhaustion' or HPA axis underfunction, seen in chronic stress, burnout, and post-traumatic stress disorder. Mainstream endocrinology does not recognise 'adrenal fatigue'; if clinical adrenal insufficiency is suspected, formal serum cortisol and ACTH stimulation testing are required. Low DHEA in isolation may reflect age-related decline or adrenal androgen insufficiency.
Note: This profile is a functional tool, not a diagnostic test for endocrine disease. Reference intervals are method-specific and less standardised than serum cortisol. Interpretation relies on the diurnal pattern and derived metrics (awakening response, slope, cortisol:DHEA ratio) rather than single time points. Results must be contextualised with clinical presentation, sleep logs, and stressor history. If Addison disease or Cushing syndrome is suspected, refer for formal endocrine evaluation with serum cortisol, ACTH, and dynamic testing.
Frequently asked questions
Salivary cortisol measures the free, bioactive fraction and is ideal for mapping diurnal rhythm and detecting circadian disruption. Serum cortisol measures total cortisol (bound and free) and is the standard for diagnosing Addison disease and Cushing syndrome. The two are complementary but not interchangeable.
How to access the Adrenal Function Profile test
The Adrenal Function Profile reference page is free and open to all practitioners. Create a free practitioner account to see pricing, save tests to your list, and generate requisition forms. Verification takes 1–2 business days.
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Published: October 7, 2026
Last reviewed: October 7, 2026
- Nieman LK, et al. The diagnosis of Cushing's syndrome: an Endocrine Society clinical practice guideline. (2008)
- Cadegiani FA, Kater CE. Adrenal fatigue does not exist: a systematic review. BMC Endocr Disord. (2016)
- Stalder T, et al. Assessment of the cortisol awakening response: expert consensus guidelines. Psychoneuroendocrinology. (2016)
- Adam EK, et al. Diurnal cortisol slopes and mental and physical health outcomes: a systematic review and meta-analysis. Psychoneuroendocrinology. (2017)
- Hellhammer DH, et al. Salivary cortisol as a biomarker in stress research. Psychoneuroendocrinology. (2009)
This content is for licensed healthcare practitioners only and does not constitute medical advice. Clinical decisions should be based on the full clinical picture and not on any single test result.