, Volume 15, Issue 1, pp 64–70 | Cite as

Cushing’s syndrome: diagnosis and surveillance using salivary cortisol



This short review summarizes the use of late-night salivary cortisol measurement in the diagnosis of Cushing’s syndrome, in the evaluation of patients with adrenal incidentalomas, and in monitoring of post-operative patients, with a focus on the different assay methodologies currently in common use. The focus is on recent studies identified by literature searches using Ovid Medline and Google Scholar as well as analysis of several recent review articles on the topic. Measurement of late night salivary cortisol (LNSC) has an excellent sensitivity and specificity for the diagnosis of Cushing’s syndrome regardless of the assay methodology used. Immunoassays have the advantage of simplicity, low cost, and small sample volume requirement, while liquid chromatography-tandem mass spectrometry has the advantage of a high specificity for cortisol and the ability to measure cortisone. The overnight dexamethasone suppression test appears to be superior to LNSC measurement in the evaluation of patients with adrenal incidentalomas. LNSC measurement is an excellent approach to monitor post-operative Cushing’s disease patients for surgical failure or recurrence. Salivary cortisol is most useful as the initial test when Cushing’s syndrome is suspected and for periodic patient monitoring after pituitary surgery for Cushing’s disease.


Salivary cortisol Cushing’s syndrome Adrenal incidentalomas Immunoassay Liquid chromatography-tandem mass spectrometry Cushing’s disease 


  1. 1.
    Raff H, Findling JW (2003) A physiologic approach to diagnosis of the Cushing syndrome. Ann Intern Med 138:980–991PubMedGoogle Scholar
  2. 2.
    Carroll T, Raff H, Findling JW (2008) Late-night salivary cortisol measurement in the diagnosis of Cushing’s syndrome. Nat Clin Pract Endocrinol Metab 4:344–350PubMedCrossRefGoogle Scholar
  3. 3.
    Findling JW, Raff H (2006) Cushing’s syndrome: important issues in diagnosis and management. J Clin Endocrinol Metab 91:3746–3753PubMedCrossRefGoogle Scholar
  4. 4.
    Findling JW, Raff H (2001) Diagnosis and differential diagnosis of Cushing’s syndrome. Endocrinol Metab Clin North Am 30:729–747PubMedCrossRefGoogle Scholar
  5. 5.
    Findling JW, Raff H (1999) Newer diagnostic techniques and problems in Cushing’s disease. Endocrinol Metab Clin North Am 28:191–210PubMedCrossRefGoogle Scholar
  6. 6.
    Findling JW, Raff H (2005) Screening and diagnosis of Cushing’s syndrome. Endocrinol Metab Clin North Am 34:385–402PubMedCrossRefGoogle Scholar
  7. 7.
    Raff H (2009) Utility of salivary cortisol measurement in Cushing’s syndrome and adrenal insufficiency. J Clin Endocrinol Metab 94:3647–3655PubMedCrossRefGoogle Scholar
  8. 8.
    Raff H (2004) Role of salivary cortisol determinations in the diagnosis of Cushing syndrome. Curr Opin Endocrinol Diab 11:271–275CrossRefGoogle Scholar
  9. 9.
    Carroll TB, Findling JW (2010) The diagnosis of Cushing’s syndrome. Rev Endocr Metab Disord 11:147–153PubMedCrossRefGoogle Scholar
  10. 10.
    Alexandraki KI, Grossman AB (2010) Novel insights in the diagnosis of Cushing’s syndrome. Neuroendocrinology 92:35–43PubMedCrossRefGoogle Scholar
  11. 11.
    Yao KJ, Moss HB, Kirillova GP (1998) Determination of salivary cortisol by nonisotopic immunoassay. Clin Biochem 31:187–190PubMedCrossRefGoogle Scholar
  12. 12.
    Gatti R, Antonelli G, Prearo M, Spinella P, Cappellin E, De Palo EF (2009) Cortisol assays and diagnostic laboratory procedures in human biological fluids. Clin Biochem 42:1205–1217PubMedCrossRefGoogle Scholar
  13. 13.
    Carrozza C, Corsello SM, Paragliola RM, Ingraudo F, Palumbo S, Locantore P, Sferrazza A, Pontecorvi A, Zuppi C (2010) Clinical accuracy of midnight salivary cortisol measured by automated electrochemiluminescence immunoassay method in Cushing’s syndrome. Ann Clin Biochem 47:228–232PubMedCrossRefGoogle Scholar
  14. 14.
    Beko G, Varba I, Glaz E, Sereg M, Feldman K, Toth M, Racz K, Patocs A (2010) Cutoff values of midnight salivary cortisol for the diagnosis of overt hypercortisolism are highly influenced by methods. Clin Chim Acta 411:364–367PubMedCrossRefGoogle Scholar
  15. 15.
    Yaneva M, Kirilov G, Zacharieva S (2009) Midnight salivary cortisol, measured by highly sensitive electrochemiluminescence immunoassay, for the diagnosis of Cushing’s syndrome. Central Eur J Med 4:59–64CrossRefGoogle Scholar
  16. 16.
    Chiu SK, Collier CP, Clark AF, Wynn-Edwards KE (2003) Salivary cortisol on ROCHE Elecsys immunoassay system: pilot biological variation studies. Clin Biochem 36:211–214PubMedCrossRefGoogle Scholar
  17. 17.
    Hansen AM, Garde AH, Christensen JM, Eller NH, Netterstrøm B (2003) Evaluation of a radioimmunoassay and establishment of a reference interval for salivary cortisol in healthy subjects in Denmark. Scand J Clin Lab Invest 63:303–310PubMedCrossRefGoogle Scholar
  18. 18.
    Baid SK, Sinaii N, Wade M, Rubino D, Nieman LK (2007) Radioimmunoassay and tandem mass spectrometry measurement of bedtime salivary cortisol levels: a comparison of assays to establish hypercortisolism. J Clin Endocrinol Metab 92:3102–3107PubMedCrossRefGoogle Scholar
  19. 19.
    Vogeser M, Durner J, Seliger E, Auernhammer C (2006) Measurement of late-night salivary cortisol with an automated immunoassay system. Clin Chem Lab Med 44:1441–1445PubMedCrossRefGoogle Scholar
  20. 20.
    Sakihara S, Kageyhama K, Oki Y, Doi M, Iwasaki Y, Takayasu S, Moriyama T, Terui K, Nibawara T, Hirata Y, Hashimoto K, Suda T (2010) Evaluation of plasma, salivary, and urinary cortisol levels for diagnosis of Cushing’s syndrome. Endocr J 57:331–337PubMedCrossRefGoogle Scholar
  21. 21.
    Perogamvros I, Owen LJ, Newell-Price J, Ray DW, Trainer PJ, Keevil B (2009) Simultaneous measurement of cortisol and cortisone in human saliva using liquid chromatography-tandem mass spectrometry: application in basal and stimulated conditions. J Chromatogr B 877:3771–3775CrossRefGoogle Scholar
  22. 22.
    Lee S, Kwon S, Shin HJ, Lim HS, Singh RJ, Lee KR, Kim YJ (2010) Simultaneous quantitative analysis of salivary cortisol and cortisone in Korean adults using LC-MS/MS. BMB Reports 43:506–511PubMedCrossRefGoogle Scholar
  23. 23.
    Jonsson BAG, Malmberg B, Amilon A, Garde AH, Orbaek P (2003) Determination of cortisol in human saliva using liquid chromatography-electrospray tandem mass spectrometry. J Chromatogr B 784:63–68CrossRefGoogle Scholar
  24. 24.
    Turpeinen U, Valimaki MJ, Hamalainen E (2009) Determination of salivary cortisol by liquid chromatography-tandem mass spectrometry. Scand J Clin Lab Invest 69:592–597PubMedCrossRefGoogle Scholar
  25. 25.
    Owen LJ, Haslam S, Adaway JE, Wood P, Glenn C, Keevil BG (2010) A simplified liquid chromatography tandem mass spectrometry assay, using on-line solid-phase extraction, for the quantitation of cortisol in saliva and comparison with a routine DELFIA method. Ann Clin Biochem 47:131–136PubMedCrossRefGoogle Scholar
  26. 26.
    Nelson EA, Palombo EA, Knowles SR (2008) Comparison of evaporation techniques for the preparation of salivary cortisol for analysis by liquid chromatography-electrospray tandem mass spectrometry. Clin Biochem 41:1413–1416PubMedCrossRefGoogle Scholar
  27. 27.
    Kataoka H, Matsuura E, Mitani K (2007) Determination of cortisol in human saliva by automated in-tube solid-phase microextraction coupled with liquid chromatography-mass spectrometry. J Pharmaceut Biomed Anal 44:160–165CrossRefGoogle Scholar
  28. 28.
    Zerikly RK, Amiri L, Faiman C, Gupta M, Singh RJ, Nutter B, Kennedy L, Hatipoglu B, Weil RJ, Hamrahian AH (2010) Diagnostic characteristics of late-night salivary cortisol using liquid chromatography-tandem mass spectrometry. J Clin Endocrinol Metab 95:4555–4559PubMedCrossRefGoogle Scholar
  29. 29.
    DePalo EF, Antonelli G, Benetazzo A, Prearo M, Gatti R (2009) Human saliva cortisone and cortisol simultaneous analysis using reverse phase HPLC technique. Clin Chim Acta 405:60–65CrossRefGoogle Scholar
  30. 30.
    Raff H, Sluss PM (2008) Pre-analytical issues for testosterone and estradiol assays. Steroids 73:1297–1304PubMedCrossRefGoogle Scholar
  31. 31.
    Broderick JE, Arnold D, Kudielka BM, Kirschbaum C (2004) Salivary cortisol sampling compliance: comparison of patients and healthy volunteers. Psychoneuroendocrinology 29:636–650PubMedCrossRefGoogle Scholar
  32. 32.
    Perogamvros I, Keevil BG, Ray DW, Trainer PJ (2010) Salivary cortisone is a potential biomarker for serum free cortisol. J Clin Endocrinol Metab 95:4951–4958PubMedCrossRefGoogle Scholar
  33. 33.
    Raff H (2008–2009) Cushing’s syndrome: diagnosis using late-night salivary cortisol measurement. Clin Lab Int (CLI) 12:6–8 (Dec 2008–Jan 2009)Google Scholar
  34. 34.
    Kivlighan KT, Granger DA, Schwartz EB, Nelson V, Curran M, Shirtcliff EA (2004) Quantifying blood leakage into the oral mucosa and its effects on the measurement of cortisol, dehydroepiandrosterone, and testosterone in saliva. Horm Behav 46:39–46PubMedCrossRefGoogle Scholar
  35. 35.
    Nunes ML, Vattaut S, Corcuff JB, Rault A, Loiseau H, Gatta B, Valli N, Letenneur L, Tabarin A (2009) Late-night salivary cortisol for diagnosis of overt and subclinical Cushing’s syndrome in hospitalized and ambulatory patients. J Clin Endocrinol Metab 94:456–462PubMedCrossRefGoogle Scholar
  36. 36.
    Cardoso EM, Arregger AL, Tumilasci OR, Contreras LN (2009) Diagnostic value of salivary cortisol in Cushing’s syndrome (CS). Clin Endocrinol (Oxf) 70:516–521CrossRefGoogle Scholar
  37. 37.
    Mullan K, Black N, Thiraviaraj A, Bell PM, Burgess C, Hunter SJ, McCance DR, Leslie H, Sheridan B, Atkinson AB (2010) Is there value in routine screening for Cushing’s syndrome in patients with diabetes. J Clin Endocrinol Metab 95:2262–2265PubMedCrossRefGoogle Scholar
  38. 38.
    Newsome S, Chen K, Hoang J, Wilson JD, Potter JM, Hickman PE (2008) Cushing’s syndrome in a clinic population with diabetes. Intern Med J 38:178–182PubMedCrossRefGoogle Scholar
  39. 39.
    Baid SK, Rubino D, Sinaii N, Ramsey S, Frank A, Nieman LK (2009) Specificity of screening tests for Cushing’s syndrome in an overweight and obese population. J Clin Endocrinol Metab 94:3857–3864PubMedCrossRefGoogle Scholar
  40. 40.
    Carroll T, Raff H, Findling JW (2009) Late-night salivary cortisol for the diagnosis of Cushing syndrome: a meta-analysis. Endocr Pract 15:335–342PubMedCrossRefGoogle Scholar
  41. 41.
    Kidambi S, Raff H, Findling JW (2007) Limitations of nocturnal salivary cortisol and urine free cortisol in the diagnosis of mild Cushing’s syndrome. Eur J Endocrinol 157:725–731PubMedCrossRefGoogle Scholar
  42. 42.
    Bardet S, Rohmer V, Boux de Casson F, Coffin C, Ronci N, Sabatier JP, Lecomte P, Audran M, Henry-Amar M, Tabarin A (2002) Bone density and biochemical bone markers in patients with adrenal incidentalomas: effect of subclinical hypercortisolism. Rev Méd Interne 23:508–517PubMedCrossRefGoogle Scholar
  43. 43.
    Chiodini I (2011) Diagnosis and treatment of subclinical hypercortisolism. J Clin Endocrinol Metab 96:1223–1236Google Scholar
  44. 44.
    Chiodini I, Morelli V, Masserini B, Salcuni AS, Eller-Vainicher C, Viti R, Coletti F, Guglielmi G, Battista C, Carnevale V, Iorio L, Beck-Peccoz P, Arosio M, Ambrosi B, Scillitani A (2009) Bone mineral density, prevalence of vertebral fractures, and bone quality in patients with adrenal incidentalomas with and without subclinical hypercortisolism: an Italian multicenter study. J Clin Endocrinol Metab 94:3207–3214PubMedCrossRefGoogle Scholar
  45. 45.
    Morelli V, Vainicher CE, Salcuni AS, Coletti F, Iorio L, Muscogiuri G, Della Casa S, Arosio M, Ambrosi B, Beck-Peccoz P, Chiodini I (2011) Risk of new vertebral fractures in patients with adrenal incidentaloma with and without subclinical hypercortisolism: a multicenter longitudinal study. J Bone Miner Res. doi: 10.1002/jbmr.398
  46. 46.
    Masserini B, Morelli V, Bergamaschi S, Ermetici F, Eller-Vainicher C, Barbieri AM, Maffini MA, Scillitani A, Ambrosi B, Beck-Peccoz P, Chiodini I (2009) The limited role of midnight salivary cortisol levels in the diagnosis of subclinical hypercortisolism in patients with adrenal incidentaloma. Eur J Endocrinol 160:87–92PubMedCrossRefGoogle Scholar
  47. 47.
    Deutschbein T, Unger N, Hinrichs J, Walz MK, Mann K, Petersenn S (2009) Late-night and low-dose dexamethasone-suppressed cortisol and serum for the diagnosis of cortisol-secretion adrenal adenomas. Eur J Endocrinol 161:747–753PubMedCrossRefGoogle Scholar
  48. 48.
    Sereg M, Toke J, Patocs A, Varga I, Igaz P, Szucs N, Horanyi J, Pusztai P, Czirjak S, Glaz E, Racz K, Toth M (2011) Diagnostic performance of salivary cortisol and serum osteocalcin measurements in patients with overt and subclinical Cushing’s syndrome. Steroids 76:38–42PubMedCrossRefGoogle Scholar
  49. 49.
    Aghi MK, Petit J, Chapman P, Loeffler J, Klibanski A, Biller BM, Swearingen B (2008) Management of recurrent and refractory Cushing’s disease with reoperation and/or proton beam radiosurgery. Clin Neurosurg 55:141–144PubMedGoogle Scholar
  50. 50.
    Carrasco CA, Coste J, Guignat L, Groussin L, Dugué MA, Gaillard S, Bertagna X, Bertherat J (2008) Midnight salivary cortisol determination for assessing the outcome of transsphenoidal surgery in Cushing’s disease. J Clin Endocrinol Metab 93:4728–4734PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Endocrine Research Laboratory, Endocrine-Diabetes CenterAurora St. Luke’s Medical CenterMilwaukeeUSA
  2. 2.Departments of Medicine, Surgery, and PhysiologyMedical College of WisconsinMilwaukeeUSA

Personalised recommendations