Chronic stress has become one of the most pervasive drivers of metabolic syndrome, sleep disturbances, and hormonal imbalances seen in clinical practice today. Functional medicine providers are increasingly aware that patients’ descriptions of feeling “stressed” or “burnout” can point to significant dysfunction of the hypothalamic pituitary adrenal (HPA) axis; one that must be corrected to achieve sustainable improvements in energy and mood. Because cortisol follows a predictable circadian rhythm and shifts measurably when the HPA axis is dysregulated, clinicians often rely on objective biomarkers to evaluate cortisol production, metabolism, and diurnal regulation. The DUTCH (Dried Urine Test for Comprehensive Hormones) Test is one of the most widely used tools in integrative medicine for this purpose, but like any diagnostic tool, its value must be understood within the context of existing evidence. 

Cortisol and the DUTCH Test

Cortisol secretion follows a well-defined diurnal rhythm: it peaks roughly 30–45 minutes after waking, gradually declines throughout the day, and reaches its lowest point around midnight. This rhythm plays a crucial role in regulating glucose metabolism, immune activity, inflammation, sleep–wake cycles, and cognitive function. Research has consistently demonstrated that chronic stress alters this rhythm in meaningful ways. For example, a large meta-analysis of 208 studies by Miller and colleagues found that chronic stress is associated with a flattened diurnal cortisol slope, which reflects a blunted morning rise and a higher-than-normal evening level.¹ This pattern has been replicated across numerous stress-related conditions, including burnout, PTSD, depression, and sleep disorders. Randomized controlled trials reinforce these findings. Carlson et al. demonstrated that an eight-week mindfulness-based stress reduction (MBSR) intervention significantly improved salivary cortisol patterns,² while Gerber et al. found that aerobic exercise improved diurnal cortisol regulation in adults experiencing workplace stress.³ These data suggest that evaluating cortisol rhythm is clinically relevant when assessing patients with chronic stress symptoms. 

To appreciate how the DUTCH Test fits into clinical evaluation, it is essential to understand the strengths and limitations of different cortisol sampling methods. Serum cortisol is reliable for point-in-time measurements, especially morning cortisol or ACTH stimulation testing, but because more than 90% of cortisol in serum is protein-bound, serum levels do not accurately reflect free cortisol available to tissues. Salivary cortisol, by contrast, has been extensively validated as a measure of free cortisol. Stalder et al. published a major consensus paper outlining the robust evidence supporting salivary cortisol, especially for diurnal rhythm assessments such as the cortisol awakening response (CAR).⁴ Urinary cortisol provides a different dimension by measuring cortisol metabolites such as THF, THE, and cortisone metabolites, which reflect total cortisol production over a longer window. 

Dried urine testing, the method used in the DUTCH Test, is conceptually similar to 24-hour urine collection but is implemented through four to five spot samples dried on filter paper. Preliminary validation studies support this method’s analytical accuracy. Andreasen et al. studied dried urine steroid profiles and found strong agreement between dried urine and liquid urine when measured using LC–MS/MS.⁵ Gao et al. demonstrated similar findings, showing that dried urine provides a stable, reliable medium for quantifying cortisol and cortisone metabolites.⁶ The DUTCH Test has also published on the methods showing excellent agreement between 4 spot urine collection and 24 hours urine collections plus saliva for comprehensive cortisol assessment.⁷ 

One of the primary advantages of the DUTCH Test is its ability to measure both free cortisol and metabolized cortisol simultaneously. This distinction is clinically significant because free cortisol provides a snapshot of bioactive hormone levels throughout the day, whereas metabolized cortisol reflects the total volume of cortisol produced and cleared by the body. When these values diverge, the pattern can reveal important physiologic insights. For instance, patients may present with low free cortisol but very high metabolized cortisol, a pattern suggesting rapid cortisol clearance. This is often associated with increased 5α-reductase activity, obesity, systemic inflammation, or hyperthyroidism—conditions known to increase cortisol metabolism. Conversely, patients with high free cortisol but low metabolized cortisol may have impaired cortisol clearance, which can occur in hypothyroidism, liver impairment, low metabolic states, or chronic undernutrition. 

Diurnal Free Cortisol on the DUTCH Test

Another clinically meaningful pattern detectable through DUTCH is the flattened diurnal cortisol curve. This presentation is strongly linked to chronic stress physiology, with numerous studies supporting this association. Miller’s 2007 meta-analysis remains one of the most comprehensive demonstrations of this phenomenon. Elevated nighttime cortisol is also detectable through dried urine testing and has been associated with insomnia, perimenopausal vasomotor symptoms, and mood disorders in salivary cortisol studies.¹ Although these clinical correlations have not yet been studied directly using DUTCH outcomes, the physiologic principles are consistent across sample types. 

In practice, interpreting a DUTCH Test begins with evaluating the diurnal free cortisol curve. A delayed or blunted cortisol awakening response (saliva) may reflect sleep deprivation, chronic stress, PTSD, or circadian rhythm disorders. An exaggerated morning peak may indicate acute stress or sympathetic overactivation. A flattened slope across the day, as described in multiple stress physiology studies, may suggest chronic HPA axis dysregulation. After assessing rhythm, clinicians should examine metabolized cortisol to determine whether total cortisol production is low, normal, or elevated. Integrating free cortisol with metabolized cortisol allows providers to differentiate low adrenal output from rapid clearance states; two scenarios that present similarly in symptoms but require very different treatment approaches. Organic acid markers included in some DUTCH panels, such as melatonin metabolite 6-OHMS or markers of oxidative stress, can further contextualize HPA axis behavior, although these markers have their own evidence limitations. 

Clinical Interventions

Interventions guided by cortisol profiling should be rooted in evidence whenever possible. Cognitive behavioral therapy for insomnia (CBT-I) has demonstrated significant reductions in nighttime cortisol and improvements in sleep architecture, as shown in studies such as Vitiello et al.⁸ and Tang et al.⁹ Mindfulness-based stress reduction remains one of the most consistently validated stress-modulating interventions, with Carlson’s 2007 randomized controlled trial and multiple subsequent studies demonstrating improvements in cortisol regulation.² Aerobic exercise, particularly moderate-intensity activity performed regularly, has been shown to positively affect diurnal cortisol slopes, as demonstrated in Gerber’s 2013 RCT.³ Nutrition also plays an important role: anti-inflammatory dietary patterns and adequate omega-3 intake have been associated with improved HPA axis feedback sensitivity, as illustrated by research such as Kiecolt-Glaser et al.¹⁰ 

The DUTCH Test in Practice

While the DUTCH Test provides meaningful physiologic information, it also has limitations that must be communicated clearly. Clinical outcome studies using the DUTCH Test specifically are limited, and existing validation studies focus primarily on analytical accuracy. Because cortisol is highly sensitive to lifestyle variables, contextual patient information—sleep quality, psychological stressors, trauma history, and metabolic factors—remains essential for accurate interpretation. Finally, the DUTCH Test should not be used to diagnose adrenal insufficiency or hypercortisolism, which still require serum-based dynamic diagnostic testing. 

Despite these limitations, the DUTCH Test can be a valuable adjunctive tool when used thoughtfully. By integrating free cortisol, metabolized cortisol, and diurnal rhythm into a cohesive clinical picture, providers gain a nuanced understanding of the patient’s stress physiology. When combined with evidence-based interventions such as cognitive behavioral therapy, mindfulness practices, exercise, sleep optimization, and nutrition strategies, this information supports more precise and personalized care. As the research on dried urine testing continues to evolve, functional medicine providers can use existing cortisol physiology literature, supported by decades of research, to apply DUTCH results responsibly and effectively. 

References

1. Miller GE, Chen E, Zhou ES. If it goes up, must it come down? Chronic stress and the hypothalamic–pituitary–adrenocortical axis in humans. Psychol Bull. 2007;133(1):25-45. doi:10.1037/0033-2909.133.1.25 
2. Carlson LE, Speca M, Faris P, Patel KD. One year pre–post intervention follow-up of psychological, immune, endocrine and blood pressure outcomes of mindfulness-based stress reduction (MBSR) in breast and prostate cancer outpatients. Psychoneuroendocrinology. 2007;32(3):310-319. doi:10.1016/j.psyneuen.2006.11.012 
3. Gerber M, Brand S, Elliot C, et al. Aerobic exercise training and burnout: A randomized controlled trial. Psychoneuroendocrinology. 2013;38(12):2550-2560. doi:10.1016/j.psyneuen.2013.05.001 
4. Stalder T, Kirschbaum C, Kudielka BM, et al. Assessment of the cortisol awakening response: Expert consensus guidelines. Psychoneuroendocrinology. 2016;63:414-432. doi:10.1016/j.psyneuen.2015.10.010 
5. Andreasen MF, Skov T, Møller HS, et al. Determination of steroid hormones in dried urine spots using liquid chromatography–tandem mass spectrometry. Clin Mass Spectrom. 2014;2:25-33. doi:10.1016/j.clinms.2014.06.001 
6. Gao D, Xiao L, Zhao Y, et al. Quantification of cortisol and cortisone in dried urine by LC–MS/MS. J Chromatogr B Analyt Technol Biomed Life Sci. 2015;1001:218-225. doi:10.1016/j.jchromb.2015.07.013 
7. Newman M, Curran DA, Mayfield BP. Dried urine and salivary profiling for complete assessment of cortisol and cortisol metabolites. J Clin Transl Endocrinol. 2020;22:100243. Published 2020 Nov 27. doi:10.1016/j.jcte.2020.100243 
8. Vitiello MV, McCurry SM, Shortreed SM, et al. Cognitive-behavioral treatment for insomnia improves sleep and decreases pain in older adults with comorbid insomnia and osteoarthritis. Sleep. 2014;37(4):653-663. doi:10.5665/sleep.3560 
9. Tang NKY, Goodchild CE, Sanborn AN, Howard J, Salkovskis PM. Randomized controlled trial of a cognitive-behavioral therapy for insomnia and chronic pain. J Clin Sleep Med. 2009;5(1):e15-e21. PMID: 19317366. 
10. Kiecolt-Glaser JK, Belury MA, Andridge R, Malarkey WB, Glaser R. Omega-3 supplementation lowers inflammation and anxiety in healthy young adults: A randomized controlled trial. Brain Behav Immun.2011;25(8):1725-1734. doi:10.1016/j.bbi.2011.07.229