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Test ID: COCOU Cortisol/Cortisone, Free, 24 Hour, Urine

Reporting Name

Cortisol/Cortisone, Free, U

Useful For

Screening test for Cushing syndrome (hypercortisolism)


Assisting in diagnosing acquired or inherited abnormalities of 11-beta-hydroxy steroid dehydrogenase (cortisol to cortisone ratio)


Diagnosis of pseudo-hyperaldosteronism due to excessive licorice consumption


This test has limited usefulness in the evaluation of adrenal insufficiency.

Clinical Information

Cortisol is a steroid hormone synthesized from cholesterol by a multienzyme cascade in the adrenal glands. It is the main glucocorticoid in humans and acts as a gene transcription factor influencing a multitude of cellular responses in virtually all tissues. Cortisol plays a critical role in glucose metabolism, maintenance of vascular tone, immune response regulation, and in the body's response to stress. Its production is under hypothalamic-pituitary feedback control.


Only a small percentage of circulating cortisol is biologically active (free), with the majority of cortisol inactive (protein bound). As plasma cortisol values increase, free cortisol (ie, unconjugated cortisol or hydrocortisone) increases and is filtered through the glomerulus. Urinary free cortisol (UFC) correlates well with the concentration of plasma free cortisol. UFC represents excretion of the circulating, biologically active, free cortisol that is responsible for the signs and symptoms of hypercortisolism. UFC is a sensitive test for the various types of adrenocortical dysfunction, particularly hypercortisolism (Cushing syndrome). A measurement of 24-hour UFC excretion, by liquid chromatography-tandem mass spectrometry (LC-MS/MS), is the preferred screening test for Cushing syndrome. LC-MS/MS methodology eliminates analytical interferences including carbamazepine (Tegretol) and synthetic corticosteroids, which can affect immunoassay-based cortisol results.


Cortisone, a downstream metabolite of cortisol, provides an additional variable to assist in the diagnosis of various adrenal disorders, including abnormalities of 11-beta-hydroxy steroid dehydrogenase (11-beta HSD), the enzyme that converts cortisol to cortisone. Deficiency of 11-beta HSD results in a state of mineralocorticoid excess because cortisol (but not cortisone) acts as a mineralocorticoid receptor agonist. Licorice (active component glycyrrhetinic acid) inhibits 11-beta HSD and excess consumption can result in similar changes.


Most patients with Cushing syndrome have increased 24-hour urinary excretion of cortisol and/or cortisone. Further studies, including suppression or stimulation tests, measurement of serum corticotropin (adrenocorticotropic hormone) concentrations, and imaging are usually necessary to confirm the diagnosis and determine the etiology.


Values in the normal range may occur in patients with mild Cushing syndrome or with periodic hormonogenesis. In these cases, continuing follow-up and repeat testing are necessary to confirm the diagnosis.


Patients with Cushing syndrome due to intake of synthetic glucocorticoids should have both suppressed cortisol and cortisone. In these circumstances a synthetic glucocorticoid screen might be ordered (call 800-533-1710).


Suppressed cortisol and cortisone values may also be observed in primary adrenal insufficiency and hypopituitarism. However, random urine specimens are not useful for evaluation of hypocorticalism. Further, many normal individuals also may exhibit a very low 24-hour urinary cortisol excretion with considerable overlap with the values observed in pathological hypocorticalism. Therefore, without other tests, 24-hour urinary cortisol measurements cannot be relied upon for the diagnosis of hypocorticalism.


Patients with 11-beta HSD deficiency may have cortisone to cortisol ratios <1, whereas a ratio of 2:1 to 3:1 is seen in normal patients. Excessive licorice consumption and use of carbenoxolone, a synthetic derivative of glycyrrhizinic acid used to treat gastroesophageal reflux disease, also may suppress the ratio to <1.

Report Available

2 to 5 days

Day(s) Performed

Monday through Saturday

Clinical Reference

1. Findling JW, Raff H: Diagnosis and differential diagnosis of Cushing's syndrome. Endocrinol Metab Clin North Am 2001;30:729-747

2. Boscaro M, Barzon L, Fallo F, Sonino N: Cushing's syndrome. Lancet 2001;357:783-791

3. Taylor RL, Machacek D, Singh RJ: Validation of a high-throughput liquid chromatography-tandem mass spectrometry method for urinary cortisol and cortisone. Clin Chem 2002;48:1511-1519

Method Name

Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS)

Specimen Type


Necessary Information

24-Hour volume is required.

Specimen Required

Supplies: Urine Tubes, 10-mL (T068)

Submission Container/Tube: Plastic, urine tube (T068)

Specimen Volume: 5 mL

Collection Instructions:

1. Collect urine for 24 hours.

2. Add 10 g of boric acid as preservative at start of collection.

Additional Information: See Urine Preservatives-Collection and Transportation for 24-Hour Urine Specimens for multiple collections.

Specimen Minimum Volume

3 mL

Specimen Stability Information

Specimen Type Temperature Time Special Container
Urine Refrigerated (preferred) 14 days
  Frozen  28 days
  Ambient  72 hours

Reference Values


0-2 years: not established

3-8 years: 1.4-20 mcg/24 hours

9-12 years: 2.6-37 mcg/24 hours

13-17 years: 4.0-56 mcg/24 hours

≥18 years: 3.5-45 mcg/24 hours



0-2 years: not established

3-8 years: 5.5-41 mcg/24 hours

9-12 years: 9.9-73 mcg/24 hours

13-17 years: 15-108 mcg/24 hours

≥18 years: 17-129 mcg/24 hours


Use the factors below to convert each analyte from mcg/24 hours to nmol/24 hours:


Conversion factors

Cortisol: mcg/24 hours x 2.76=nmol/24 hours (molecular weight=362.5)

Cortisone: mcg/24 hours x 2.78=nmol/24 hours (molecular weight=360)


For SI unit Reference Values, see

Test Classification

This test was developed, and its performance characteristics determined by Mayo Clinic in a manner consistent with CLIA requirements. This test has not been cleared or approved by the US Food and Drug Administration.

CPT Code Information

82530-Cortisol; free


LOINC Code Information

Test ID Test Order Name Order LOINC Value
COCOU Cortisol/Cortisone, Free, U 101319-2


Result ID Test Result Name Result LOINC Value
8546 Cortisol, U 14158-0
10327 Cortisone, U 14044-2
TM93 Collection Duration 13362-9
VL47 Urine Volume 3167-4

Urine Preservative Collection Options

Note: The addition of preservative or application of temperature controls must occur at the start of the collection.







50% Acetic Acid


Boric Acid


Diazolidinyl Urea


6M Hydrochloric Acid


6M Nitric Acid


Sodium Carbonate






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