Is the salivary cortisol test effective in detecting exogenous steroid abuse?

Salivary Cortisol Testing for Exogenous Steroid Abuse Detection

Salivary cortisol testing is not recommended for detecting exogenous steroid abuse due to its limited utility, poor specificity, and multiple confounding factors that affect results. 1

Limitations of Salivary Cortisol for Steroid Abuse Detection

Physiological Considerations

• Salivary cortisol primarily reflects free (unbound) cortisol in circulation 2
• While this provides information about the biologically active cortisol fraction, it has significant limitations for detecting exogenous steroid use:
  • Significant diurnal variation affects interpretation 1
  • Multiple confounding factors influence results including:
    • Gender, age, time of sampling, and saliva volume 1
    • Physical activity and psychological stress 2
    • Sampling technique and collection method 3

Technical and Practical Challenges

• Implementation concerns with salivary sampling:
  • Inadequate saliva volume in many patients
  • Blood contamination invalidating results
  • Enzyme immunoassay availability limitations 1
• The Society of Critical Care Medicine and European Society of Intensive Care Medicine specifically recommend against using salivary cortisol over serum cortisol for diagnosing cortisol-related disorders 1

Preferred Testing Methods for Steroid Abuse

Recommended Approach

• High-dose (250-μg) ACTH stimulation test is preferred over salivary testing 1
  • Provides more reliable assessment of adrenal function
  • Better established reference ranges
  • Higher diagnostic accuracy (sensitivity and specificity)

Alternative Testing Options

• Overnight 1-mg dexamethasone suppression test (DST) 1
  • More sensitive for detecting disruptions in the HPA axis
  • Provides better assessment of feedback inhibition, which is affected by exogenous steroid use
• 24-hour urinary free cortisol (UFC) measurements 1
  • Reflects overall cortisol production
  • Independent of cortisol-binding globulin changes
  • Requires multiple collections (at least 2-3) for accuracy

Pitfalls and Caveats

• Salivary cortisol testing has been validated primarily for:

  • Assessing diurnal cortisol rhythm 1
  • Diagnosing endogenous hypercortisolism (Cushing's syndrome) 1
  • NOT for detecting exogenous steroid abuse

• Common issues affecting interpretation:

  • Mass spectrometry can detect both cortisol and cortisone, improving sensitivity but reducing specificity 1
  • Disruption of normal day/night cycle (e.g., night-shift workers) invalidates results 1
  • Poor reproducibility of salivary cortisol measurements over time 4, 3

• Potential false results:

  • Topical hydrocortisone preparations can contaminate samples 1
  • Certain medications can interfere with results
  • Stress-induced cortisol elevations can mask or mimic abnormalities

Conclusion

For detecting exogenous steroid abuse, more established methods like the high-dose ACTH stimulation test, dexamethasone suppression test, or 24-hour urinary free cortisol collections provide more reliable and interpretable results than salivary cortisol testing. The evidence strongly suggests avoiding salivary cortisol for this specific purpose.