Test Id : SALCC
Cortisol and Cortisone, Saliva
Useful For
Suggests clinical disorders or settings where the test may be helpful
Screening and diagnosis of Cushing syndrome/hypercortisolism
Adjunctive evaluation of adrenal insufficiency (using waking salivary cortisone/cortisol)
May be useful to assess for hypercortisolism/other adrenal disorders during pregnancy/oral estrogen therapy (when total cortisol is increased due to increase in cortisol-binding globulin) or in states of low cortisol-binding globulin (critical illness)
Evaluation of suspected contamination from topical steroids
Method Name
A short description of the method used to perform the test
Liquid Chromatography Tandem Mass Spectrometry (LC-MS/MS)
NY State Available
Indicates the status of NY State approval and if the test is orderable for NY State clients.
Reporting Name
Lists a shorter or abbreviated version of the Published Name for a test
Aliases
Lists additional common names for a test, as an aid in searching
Nighttime Salivary Cortisol
Late-Night Salivary Cortisol
Salivary Cortisol and Cortisone
Salivary Hydrocortisone
LNSC
Specimen Type
Describes the specimen type validated for testing
Saliva
Necessary Information
Collection time is required.
Specimen Required
Defines the optimal specimen required to perform the test and the preferred volume to complete testing
If multiple specimens are collected, submit each Salivette under a separate order number.
Patient Preparation:
1. Patient should not brush teeth, eat, drink, or take any oral medication for at least 60 minutes before specimen collection.
2. Have patient rinse mouth thoroughly with water for 1 to 5 seconds. Wait 10 minutes before collecting the specimen to avoid contamination of the saliva by an interfering substance.
Supplies: Cortisol, Saliva Collection Kit (T514)
Container/Tube: Sarstedt Salivette
Specimen Volume: 1.5 mL
Collection Instructions:
1. Provide patient with a Saliva Collection Kit (Salivette) containing the Cortisol and Cortisone - Saliva Collection Instructions and ask them to follow the instructions as written.
2. If performing a late-night salivary cortisol (LNSC) test, specimen should be collected immediately prior to going to bed. If patient is undergoing assessment for adrenal insufficiency, specimen should be collected immediately after waking up. The patient should follow their normal sleeping schedule. Record collection time on the Cortisol and Cortisone - Saliva Collection Instructions sheet.
3. Instruct patient to return Cortisol and Cortisone - Saliva Collection Instructions with the appropriately labeled Salivette to the laboratory.
Additional Information: Reference intervals are available for LNSC testing (immediately before going to bed) and immediately after waking for assessment of adrenal insufficiency.
Special Instructions
Library of PDFs including pertinent information and forms related to the test
Specimen Minimum Volume
Defines the amount of sample necessary to provide a clinically relevant result as determined by the testing laboratory. The minimum volume is sufficient for one attempt at testing.
0.6 mL
Reject Due To
Identifies specimen types and conditions that may cause the specimen to be rejected
Specimen Stability Information
Provides a description of the temperatures required to transport a specimen to the performing laboratory, alternate acceptable temperatures are also included
| Specimen Type | Temperature | Time | Special Container |
|---|---|---|---|
| Saliva | Refrigerated (preferred) | 28 days | |
| Ambient | 14 days | ||
| Frozen | 60 days |
Useful For
Suggests clinical disorders or settings where the test may be helpful
Screening and diagnosis of Cushing syndrome/hypercortisolism
Adjunctive evaluation of adrenal insufficiency (using waking salivary cortisone/cortisol)
May be useful to assess for hypercortisolism/other adrenal disorders during pregnancy/oral estrogen therapy (when total cortisol is increased due to increase in cortisol-binding globulin) or in states of low cortisol-binding globulin (critical illness)
Evaluation of suspected contamination from topical steroids
Clinical Information
Discusses physiology, pathophysiology, and general clinical aspects, as they relate to a laboratory test
Cortisol secretion is regulated through the hypothalamic-pituitary-adrenal axis. The diagnosis of both Cushing syndrome (CS) and adrenal insufficiency (AI) relies largely on cortisol measurements. CS results from chronic endogenous glucocorticoid excess and may be pituitary, ectopic, or adrenal in origin. In contrast, AI reflects cortisol deficiency that may be primary or central.
Cortisol follows a circadian rhythm, with peak levels in the early morning and a nadir around midnight. In most patients with CS, this circadian pattern is disrupted, with inappropriately elevated late-night cortisol concentrations. Measurement of late-night salivary cortisol (LNSC), collected immediately prior to going to bed, is a recommended first-line diagnostic test for hypercortisolism. Conversely, measurement of cortisol upon waking is a first line test for AI.
Salivary cortisol testing offers several advantages: it is noninvasive, stable at room temperature, and reflects the free, biologically active cortisol fraction. In the salivary glands, cortisol is rapidly converted to cortisone via 11beta-hydroxysteroid dehydrogenase type 2. Because salivary cortisol can be affected by contamination (eg, topical hydrocortisone, gingival bleeding), salivary cortisone is often a more reliable marker of endogenous cortisol production. Studies suggest that salivary cortisone performs as well or better than salivary cortisol in detecting hypercortisolism. As such, measuring salivary cortisone in addition to cortisol may improve diagnostic accuracy, reduce indeterminate results, and help identify contamination. Emerging evidence also supports the use of waking salivary cortisol and cortisone measurements to diagnose or exclude AI, potentially reducing the need for dynamic testing and offering greater convenience for patients.
Reference Values
Describes reference intervals and additional information for interpretation of test results. May include intervals based on age and sex when appropriate. Intervals are Mayo-derived, unless otherwise designated. If an interpretive report is provided, the reference value field will state this.
Cortisol:
Immediately after waking: 85-620 ng/dL
Immediately prior to going to bed: <127 ng/dL
Cortisone:
Immediately after waking: 510-2110 ng/dL
Immediately prior to going to bed: 62-624 ng/dL
Cortisol/Cortisone Ratio interpretation:
Cortisol should be lower than cortisone in saliva. A ratio greater than 1 suggests contamination with blood or exogenous cortisol. A ratio greater than 2 indicates contamination is likely. In these cases, recollection is recommended.
Interpretation
Provides information to assist in interpretation of the test results
Cushing syndrome/hypercortisolism:
Both salivary cortisol and cortisone should be low at night. In Cushing syndrome (CS), late night concentrations of both analytes are typically elevated due to loss of the normal circadian nadir. Diagnosis typically requires concordant evidence from additional tests, such as overnight dexamethasone suppression testing and 24-hour urine cortisol assessment.
Late night salivary cortisone offers improved sensitivity and specificity compared to salivary cortisol.
Late-night salivary cortisol levels above 110-145 ng/dL are considered abnormal, suggestive of hypercortisolism.
Late night salivary cortisone levels above 487-649 ng/dL are considered abnormal, suggestive of hypercortisolism.
Adrenal insufficiency:
Waking salivary cortisone and/or cortisol measurements can help exclude or suggest adrenal insufficiency (AI) and may reduce the need for dynamic testing
Based on the 2023 study by Debono et al*:
Waking salivary cortisone greater than 612 ng/dL excludes AI
Waking salivary cortisol greater than 180 ng/dL excludes AI
Waking salivary cortisone less than 251 ng/dL diagnoses AI
Waking salivary cortisol less than 25 ng/dL diagnoses AI
*In NEJM study by Debono et al from 2023, the area under the curve (AUC) of waking salivary cortisone was 0.95. A cutoff of greater than 612 ng/dL had a sensitivity of 97%, specificity of 67%, and a negative predictive value (NPV) of 96% for excluding adrenal insufficiency. A cutoff of less than251 ng/dL had a sensitivity of 76%, specificity of 97%, and positive predictive value (PPV) of 95% in confirming adrenal insufficiency. In the same study, salivary cortisol performed worse (AUC of 0.89), with cutoff of >180 ng/dL having NPV of 94% and <25 ng/dL - PPV of 93%.
In addition, based on the in-house study of 640 patients with paired venipuncture-based serum cortisol and salivary cortisol and cortisone, corresponding serum cortisol - salivary cortisol and cortisone thresholds are listed below.
Table. Salivary steroid thresholds corresponding to serum steroid measurements
| Serum cortisol cutoff | Saliva steroids | Area under the curve (95% CI) | Optimized cutoff | Rule-out threshold (95% sensitivity) | Rule-in threshold (95% specificity) |
| < or =1.8 | Cortisone | 0.98 (0.96-0.99) | 117 | 102 | 122 |
| | Cortisol | 0.91 (0.89-0.94) | 17 | <10 | 32 |
| < or =5 | Cortisone | 0.99 (0.98-1.00) | 327 | 300 | 332 |
| | Cortisol | 0.99 (0.98-0.99) | 36 | 35 | 44 |
| > or =10 | Cortisone | 0.99 (0.99-1.00) | 650 | 375 | 822 |
| | Cortisol | 0.99 (0.99-1.00) | 83 | 50 | 190 |
| > or =18 | Cortisone | 0.99 (0.99-1.00) | 1232 | 780 | 1447 |
| | Cortisol | 0.99 (0.99-1.00) | 378 | 173 | 456 |
Cortisol/cortisone ratio greater than 1 is suggestive of contamination.
Cautions
Discusses conditions that may cause diagnostic confusion, including improper specimen collection and handling, inappropriate test selection, and interfering substances
Several factors may influence results:
-Stress, acute illness, psychiatric conditions, alcohol use, and certain medications can elevate levels
-Timing of collection is critical due to circadian variation
-Irregular sleep schedules (eg, shift work) may affect interpretation
-Topical hydrocortisone may falsely elevate salivary cortisol, whereas cortisone is less affected
Clinical Reference
Recommendations for in-depth reading of a clinical nature
1. Vaidya A, Findling J, Bancos I. Adrenal insufficiency in adults: A review. JAMA. 2025;334(8):714-725
2. Berndt V, Dahlqvist P, de Verdier J, Ryberg H, Ragnarsson O. The diagnostic value of salivary cortisol and salivary cortisone in patients with suspected hypercortisolism. Front Endocrinol (Lausanne). 2022;13:1028804
3. Backlund N, Brattsand G, Israelsson M, et al. Reference intervals of salivary cortisol and cortisone and their diagnostic accuracy in Cushing's syndrome. Eur J Endocrinol. 2020;182(6):569-582
4. Lages AS, Frade JG, Oliveira D, et al. Late-night salivary cortisol: cut-off definition and diagnostic accuracy for Cushing's syndrome in a portuguese population. Acta Med Port. 2019;32(5):381-387
5. Ponzetto F, Settanni F, Parasiliti-Caprino M, et al. Reference ranges of late-night salivary cortisol and cortisone measured by LC-MS/MS and accuracy for the diagnosis of Cushing's syndrome. J Endocrinol Invest. 2020;43(12):1797-1806
6. van Baal L, Wichert M, Zwanziger D, et al. Distinct Late-Night Salivary Cortisol Cut-Off Values for the Diagnosis of Hypercortisolism. Horm Metab Res. 2021;53(10):662-671
7. Debono M, Elder CJ, Lewis J, et al. Home waking salivary cortisone to screen for adrenal insufficiency. NEJM Evid. 2023.2(2):p.EVIDoa2200182
8. Fleseriu M, Auchus R, Bancos I, et al. Consensus on diagnosis and management of Cushing's disease: a guideline update. Lancet Diabetes Endocrinol. 2021;9(12):847-875
9. Mohamed RS, Abuelgasim B, Barker S, et al. Late-night salivary cortisol and cortisone should be the initial screening test for Cushing's syndrome. Endocr Connect. 2022;11(7):e220050
10. Debono M, Caunt S, Elder C, et al. Real world evidence supports waking salivary cortisone as a screening test for adrenal insufficiency. Clin Endocrinol (Oxf). 2023;99(6):517-524
11. Kvam Hellan K, Lyngstad M, Methlie P, Lovas K, Husebye ES, Ueland GA. Utility of salivary cortisol and cortisone in the diagnostics of adrenal insufficiency. J Clin Endocrinol Metab, 2025.110(5):1218-1223
12. Langelaan MLP, Kisters JMH, Oosterwerff MM, Boer AK. Salivary cortisol in the diagnosis of adrenal insufficiency: cost efficient and patient friendly. Endocr Connect. 2018;7(4):560-566
Method Description
Describes how the test is performed and provides a method-specific reference
Isotopically labeled cortisol and cortisone are added to the sample as internal standards. Cortisol, cortisone, and coinciding internal standards are extracted from the specimens using online solid phase extraction (SPE) followed by liquid chromatography tandem mass spectrometry (LC-MS/MS) analysis.(Unpublished Mayo method)
PDF Report
Indicates whether the report includes an additional document with charts, images or other enriched information
Day(s) Performed
Outlines the days the test is performed. This field reflects the day that the sample must be in the testing laboratory to begin the testing process and includes any specimen preparation and processing time before the test is performed. Some tests are listed as continuously performed, which means that assays are performed multiple times during the day.
Monday through Friday
Report Available
The interval of time (receipt of sample at Mayo Clinic Laboratories to results available) taking into account standard setup days and weekends. The first day is the time that it typically takes for a result to be available. The last day is the time it might take, accounting for any necessary repeated testing.
Specimen Retention Time
Outlines the length of time after testing that a specimen is kept in the laboratory before it is discarded
Performing Laboratory Location
Indicates the location of the laboratory that performs the test
Fees
Several factors determine the fee charged to perform a test. Contact your U.S. or International Regional Manager for information about establishing a fee schedule or to learn more about resources to optimize test selection.
- Authorized users can sign in to Test Prices for detailed fee information.
- Clients without access to Test Prices can contact Customer Service 24 hours a day, seven days a week.
- Prospective clients should contact their account representative. For assistance, contact Customer Service.
Test Classification
Provides information regarding the medical device classification for laboratory test kits and reagents. Tests may be classified as cleared or approved by the US Food and Drug Administration (FDA) and used per manufacturer instructions, or as products that do not undergo full FDA review and approval, and are then labeled as an Analyte Specific Reagent (ASR) product.
This test was developed and its performance characteristics determined by Mayo Clinic in a manner consistent with CLIA requirements. It has not been cleared or approved by the US Food and Drug Administration.
CPT Code Information
Provides guidance in determining the appropriate Current Procedural Terminology (CPT) code(s) information for each test or profile. The listed CPT codes reflect Mayo Clinic Laboratories interpretation of CPT coding requirements. It is the responsibility of each laboratory to determine correct CPT codes to use for billing.
CPT codes are provided by the performing laboratory.
CPT codes are provided by the performing laboratory.
82530
82542
LOINC® Information
Provides guidance in determining the Logical Observation Identifiers Names and Codes (LOINC) values for the order and results codes of this test. LOINC values are provided by the performing laboratory.
| Test Id | Test Order Name | Order LOINC Value |
|---|---|---|
| SALCC | Cortisol and Cortisone, Saliva | In Process |
| Result Id | Test Result Name |
Result LOINC Value
Applies only to results expressed in units of measure originally reported by the performing laboratory. These values do not apply to results that are converted to other units of measure.
|
|---|---|---|
| 623629 | Cortisol Saliva | 2142-8 |
| 623630 | Cortisone Saliva | In Process |
| 623631 | Cortisol/Cortisone ratio | In Process |