ASP Collection Pack
ASP Collection Pack
Adrenocortex Stress Profile — A Comprehensive Tool to Assess the HPA Axis — Stress Response and Resiliency

Specimen Type: Saliva

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Why choose Genova Diagnostics' Hormonal Health Products?

HPA axis dysfunction is seen as a root cause for disease, making evaluation vital to a patient’s overall health.

Genova’s ASP is comprehensive – assessing cortisol diurnal rhythm, DHEA, and optional cortisol awakening response (CAR).

Salivary testing is an easy, non-invasive, at-home collection.

A Comprehensive Tool to Assess the HPA Axis — Stress Response and Resiliency

The Adrenocortex Stress Profile (ASP) provides an assessment of the Hypothalamic-Pituitary-Adrenal (HPA) axis using carefully timed salivary samples of the hormones cortisol and DHEA. Salivary testing is an easy, non-invasive option to measure unbound, biologically active parent hormone levels. The report offers an easy-to-interpret graphic which plots the results of the natural diurnal rhythm.

 

Which patients might benefit from HPA axis testing?

Daily hassles, chronic pain, blood sugar dysregulation, work stressors, and poor relationship quality can alter the HPA axis. Imbalances in adrenal hormones can have a wide range of negative consequences that can adversely impact a patient's overall quality of life.

HPA axis dysfunction is associated with many conditions including but not limited to:1,2,3,4,5,6,7,8,9

  • Hypertension
  • Cardiovascular disease
  • Gastrointestinal and immune dysregulation
  • Diabetes and metabolic syndrome
  • Depression
  • Chronic fatigue
  • Insomnia
  • Weight gain
  • Persistent pain
  • Neurodegenerative disease and cognitive decline

 

About the Adrenocortex Stress Profile

  • Four cortisol samples measured throughout the day give insight into the natural circadian diurnal cortisol rhythm, and help clinicians address specific daily stressors.
  • DHEA is measured once in the 7:00 AM – 9:00 AM sample.
  • Ratio of DHEA to cortisol is calculated to provide insight into anabolic/catabolic balance.

Optional Add-on:

  • Cortisol Awakening Response (CAR)
    • Two awakening samples to evaluate CAR.
    • CAR is a transient, immediate rise in cortisol upon awakening and is distinct from the diurnal rhythm. CAR reflects a person's ability to cope with anticipated challenges and their perception of control around chronic stress, providing insight into HPA axis resiliency.

Adrenocortex Stress Profile testing can reveal these HPA axis imbalances and provide direction for clinical intervention with targeted therapeutic treatments such as nutrient support and/or adaptogens, stress management, behavioral modification and lifestyle interventions.

In response to stress, your adrenal glands produce hormones that can have a negative impact on your overall health.

There are many conditions associated with adrenal imbalances:

  • High blood pressure
  • Cardiovascular disease
  • Gastrointestinal and immune issues
  • Diabetes and metabolic syndrome
  • Depression
  • Chronic fatigue
  • Sleep issues
  • Weight gain
  • Persistent pain
  • Nervous system diseases
  • Memory and thinking issues

Adrenocortex Stress Profile testing can reveal adrenal hormone imbalances and can help your practitioner create a therapeutic plan. Patients often report having more energy, better sleep, improved mood, and clearer thinking when adrenal imbalances are corrected.

The Adrenocortex Stress Profile requires 4-6 saliva samples throughout the day. We have many resources to help make your testing experience a success. Review the Test Preparation tab to learn more about the collection process.

Preparing for this Test

Certain medications and supplements may impact test results, though in some instances that impact is unknown. There are many substances that influence cortisol and DHEA levels, however no known substances will interfere with the ability to run the assay itself.

Genova never recommends that patients discontinue medically necessary medications or supplements in order to complete testing.

There may be times when a patient may stay on a medication or dietary supplement during testing in order to evaluate its effectiveness or impact. A clinician may choose to discontinue a substance in order to evaluate the patient's baseline. The timeframe to discontinue varies for each substance and is at the discretion of the clinician.

Any questions regarding a medication or supplement impact on biomarker results can be researched by contacting the medication/supplement manufacturer and/or searching the literature (PubMed, Google Scholar) for relevant information. Drug databases such as drugs.com, rxlist.com, or Epocrates may provide additional information.

Glucocorticoids

Any steroid-based preparation including oral, topical (patch, cream), eye drops (minimal impact), nasal sprays, injections, and inhalers may influence the Adrenocortex Stress Profile findings.1-11 The degree of impact depends on numerous factors including, but not limited to, preparation, specific drug, dosage, chronicity of use, and individual response to medications. Not all glucocorticoids impact results the same.7

In general, exogenous glucocorticoids - even with one-time administration - are known to suppress the HPA axis via negative feedback, which can result in lower endogenous production of cortisol.3,12,13 Long-term use of glucocorticoids can lead to adrenal atrophy, which is slowly reversible.12,13 Glucocorticoid-induced adrenal insufficiency may last up to 2-4 years after glucocorticoid withdrawal.14

When to test a patient following glucocorticoid discontinuation is dependent on multiple factors (mentioned above) and is at the discretion of the clinician. For example, if a clinician wishes to test a patient's baseline HPA axis function following a steroid injection, it may take up to 4 weeks or longer for recovery to baseline.6,8 A literature search may provide further insight into the clearance rate and impact the particular glucocorticoid may have on salivary testing.

The cortisol assay can cross-react with various glucocorticoid drugs. For example, there is a strong cross-reactivity with the antibody used in this assay and dexamethasone which may result in a false elevation of cortisol. It is unknown how much of the reported result is the patient's endogenous cortisol, versus how much is cross-reactivity from the medication.

Genova's hormone assays measure endogenous hormones as well as bioidentical hormone replacement, but not synthetic hormones, due to their different molecular structure. Hydrocortisone is bioidentical cortisol and is prescribed for patients with adrenal insufficiency. Some studies suggest utility of salivary cortisol measurements for monitoring glucocorticoid replacement therapy, however studies are mixed.15

Shift Workers and Alternate Sleep-Wake Schedules

The reference ranges for the Adrenocortex Stress Profile (ASP) were designed for patients with normal sleep cycles and referenced for the specific time frames as graphed on the test report. However, some clinicians choose to test individuals with altered sleep cycles, knowing that the graph, and reference ranges may not directly apply. Even though the reference ranges may not apply, there is still some clinical information to be gleaned based on the overall slope of the diurnal curve. It is unknown whether extrapolating from the diurnal curve and reference ranges would apply to someone on an alternate schedule - "healthy" or "normal" has not been defined for this population.16-19 If the clinician chooses to test, the clinician can change the morning peak time to the patient's waking time (within one hour of waking) and then each additional sample will be approximately four hours after the prior.

In order to determine cortisol awakening response (CAR), samples must include both the waking and 30-minute samples. The timing of these collections should reflect when the patient wakes to begin their day. It has been shown in literature that patients who have alternate work schedules may 'reset' their internal circadian rhythm and, therefore, CAR sampling can be done during their normal waking cycle. When the patient wakes, have them immediately give a saliva sample, then another exactly 30 minutes later for CAR. These two samples are used for the CAR calculation. The third sample should be within that hour, then every four hours after that to complete the ASP portion.

Bleeding Gums

Samples visibly contaminated with blood should be recollected. This can result in a false elevation of hormones. Blood concentrations of steroid hormones are several-fold higher than saliva levels.20,21 For this reason, brushing and flossing is discouraged for 1 hour prior to salivary collection. Additionally, if the patient has a condition that causes gums to bleed easily, such as gingivitis or periodontitis, or has dentures and other oral appliances, a plan should be in place to ensure gums do not bleed during testing.

Pediatric Patients

The reference ranges for the Adrenocortex Stress Profile are based off a healthy cohort of patients aged greater than 18. Genova does not have pediatric reference ranges. DHEA is an androgen and is typically lower in prepubescent populations. A literature search may provide further insight into pediatric reference ranges for cortisol and DHEA.

 

References
  1. Pandya D, Puttanna A, Balagopal V. Systemic effects of inhaled corticosteroids: an overview. The Open Resp Med J. 2014;8:59-65.
  2. Sastre J, Mosges R. Local and systemic safety of intranasal corticosteroids. J Invest Allergol Clin Immunol. 2012;22(1):1-12.
  3. Baptist AP, Reddy RC. Inhaled corticosteroids for asthma: are they all the same? J Clin Pharm Therap. 2009;34(1):1-12.
  4. Stout A, Friedly J, Standaert CJ. Systemic Absorption and Side Effects of Locally Injected Glucocorticoids. PM & R : J Injury Function Rehab. 2019;11(4):409-419.
  5. Masharani U, Shiboski S, Eisner MD, et al. Impact of exogenous glucocorticoid use on salivary cortisol measurements among adults with asthma and rhinitis. Psychoneuroendocrinology. 2005;30(8):744-752.
  6. Habib GS. Systemic effects of intra-articular corticosteroids. Clinical Rheumatol. 2009;28(7):749-756.
  7. Broersen LH, Pereira AM, Jørgensen JO, Dekkers OM. Adrenal Insufficiency in Corticosteroids Use: Systematic Review and Meta-Analysis. J Clin Endocrinol Metab. 2015;100(6):2171-2180.
  8. Chon JY, Moon HS. Salivary cortisol concentration changes after epidural steroid injection. Pain Phys. 2012;15(6):461-466.
  9. Silver S, Tuppal R, Gupta AK, et al. Effect of calcipotriene plus betamethasone dipropionate topical suspension on the hypothalamic-pituitary-adrenal axis and calcium homeostasis in subjects with extensive psoriasis vulgaris: an open, non-controlled, 8-week trial. J Drugs Dermatol. 2013;12(8):882-887.
  10. Krupin T, Mandell AI, Podos SM, Becker B. Topical corticosteroid therapy and pituitary-adrenal function. Arch Ophthal. 1976;94(6):919-920.
  11. Sandhu SS, Smith JM, Doherty M, James A, Figueiredo FC. Do topical ophthalmic corticosteroids suppress the hypothalmic-pituitary-adrenal axis in post-penetrating keratoplasty patients? Eye. 2012;26(5):699-702.
  12. Ambrogio AG, Pecori Giraldi F, Cavagnini F. Drugs and HPA axis. Pituitary. 2008;11(2):219-229.
  13. Lipworth BJ. Systemic adverse effects of inhaled corticosteroid therapy: A systematic review and meta-analysis. Arch Int Med. 1999;159(9):941-955.
  14. Pelewicz K, Miśkiewicz P. Glucocorticoid Withdrawal-An Overview on When and How to Diagnose Adrenal Insufficiency in Clinical Practice. Diagnostics. 2021;11(4).
  15. Jung C, Greco S, Nguyen HH, et al. Plasma, salivary and urinary cortisol levels following physiological and stress doses of hydrocortisone in normal volunteers. BMC Endo Dis. 2014;14:91.
  16. Cannizzaro E, Cirrincione L, Mazzucco W, et al. Night-Time Shift Work and Related Stress Responses: A Study on Security Guards. Int J Environ Res Public Health. 2020;17(2).
  17. Lindholm H, Ahlberg J, Sinisalo J, et al. Morning cortisol levels and perceived stress in irregular shift workers compared with regular daytime workers. Sleep Dis. 2012;2012:789274.
  18. Li J, Bidlingmaier M, Petru R, Pedrosa Gil F, Loerbroks A, Angerer P. Impact of shift work on the diurnal cortisol rhythm: a one-year longitudinal study in junior physicians. J Occup Med Toxicol. 2018;13:23.
  19. Bostock S, Steptoe A. Influences of early shift work on the diurnal cortisol rhythm, mood and sleep: within-subject variation in male airline pilots. Psychoneuroendocrinology. 2013;38(4):533-541.
  20. Hofman LF. Human saliva as a diagnostic specimen. J Nutr. 2001;131(5):1621s-1625s.
  21. Granger DA, Taylor MK. Salivary bioscience: foundations of interdisciplinary saliva research and applications. Springer Nature; 2020.

A Comprehensive Tool to Assess the HPA Axis — Stress Response and Resiliency

The Adrenocortex Stress Profile (ASP) provides an assessment of the Hypothalamic-Pituitary-Adrenal (HPA) axis using carefully timed salivary samples of the hormones cortisol and DHEA. Salivary testing is an easy, non-invasive option to measure unbound, biologically active parent hormone levels. The report offers an easy-to-interpret graphic which plots the results of the natural diurnal rhythm.

 

Which patients might benefit from HPA axis testing?

Daily hassles, chronic pain, blood sugar dysregulation, work stressors, and poor relationship quality can alter the HPA axis. Imbalances in adrenal hormones can have a wide range of negative consequences that can adversely impact a patient's overall quality of life.

HPA axis dysfunction is associated with many conditions including but not limited to:1,2,3,4,5,6,7,8,9

  • Hypertension
  • Cardiovascular disease
  • Gastrointestinal and immune dysregulation
  • Diabetes and metabolic syndrome
  • Depression
  • Chronic fatigue
  • Insomnia
  • Weight gain
  • Persistent pain
  • Neurodegenerative disease and cognitive decline

 

About the Adrenocortex Stress Profile

  • Four cortisol samples measured throughout the day give insight into the natural circadian diurnal cortisol rhythm, and help clinicians address specific daily stressors.
  • DHEA is measured once in the 7:00 AM – 9:00 AM sample.
  • Ratio of DHEA to cortisol is calculated to provide insight into anabolic/catabolic balance.

Optional Add-on:

  • Cortisol Awakening Response (CAR)
    • Two awakening samples to evaluate CAR.
    • CAR is a transient, immediate rise in cortisol upon awakening and is distinct from the diurnal rhythm. CAR reflects a person's ability to cope with anticipated challenges and their perception of control around chronic stress, providing insight into HPA axis resiliency.

Adrenocortex Stress Profile testing can reveal these HPA axis imbalances and provide direction for clinical intervention with targeted therapeutic treatments such as nutrient support and/or adaptogens, stress management, behavioral modification and lifestyle interventions.

In response to stress, your adrenal glands produce hormones that can have a negative impact on your overall health.

There are many conditions associated with adrenal imbalances:

  • High blood pressure
  • Cardiovascular disease
  • Gastrointestinal and immune issues
  • Diabetes and metabolic syndrome
  • Depression
  • Chronic fatigue
  • Sleep issues
  • Weight gain
  • Persistent pain
  • Nervous system diseases
  • Memory and thinking issues

Adrenocortex Stress Profile testing can reveal adrenal hormone imbalances and can help your practitioner create a therapeutic plan. Patients often report having more energy, better sleep, improved mood, and clearer thinking when adrenal imbalances are corrected.

The Adrenocortex Stress Profile requires 4-6 saliva samples throughout the day. We have many resources to help make your testing experience a success. Review the Test Preparation tab to learn more about the collection process.

Preparing for this Test

Certain medications and supplements may impact test results, though in some instances that impact is unknown. There are many substances that influence cortisol and DHEA levels, however no known substances will interfere with the ability to run the assay itself.

Genova never recommends that patients discontinue medically necessary medications or supplements in order to complete testing.

There may be times when a patient may stay on a medication or dietary supplement during testing in order to evaluate its effectiveness or impact. A clinician may choose to discontinue a substance in order to evaluate the patient's baseline. The timeframe to discontinue varies for each substance and is at the discretion of the clinician.

Any questions regarding a medication or supplement impact on biomarker results can be researched by contacting the medication/supplement manufacturer and/or searching the literature (PubMed, Google Scholar) for relevant information. Drug databases such as drugs.com, rxlist.com, or Epocrates may provide additional information.

Glucocorticoids

Any steroid-based preparation including oral, topical (patch, cream), eye drops (minimal impact), nasal sprays, injections, and inhalers may influence the Adrenocortex Stress Profile findings.1-11 The degree of impact depends on numerous factors including, but not limited to, preparation, specific drug, dosage, chronicity of use, and individual response to medications. Not all glucocorticoids impact results the same.7

In general, exogenous glucocorticoids - even with one-time administration - are known to suppress the HPA axis via negative feedback, which can result in lower endogenous production of cortisol.3,12,13 Long-term use of glucocorticoids can lead to adrenal atrophy, which is slowly reversible.12,13 Glucocorticoid-induced adrenal insufficiency may last up to 2-4 years after glucocorticoid withdrawal.14

When to test a patient following glucocorticoid discontinuation is dependent on multiple factors (mentioned above) and is at the discretion of the clinician. For example, if a clinician wishes to test a patient's baseline HPA axis function following a steroid injection, it may take up to 4 weeks or longer for recovery to baseline.6,8 A literature search may provide further insight into the clearance rate and impact the particular glucocorticoid may have on salivary testing.

The cortisol assay can cross-react with various glucocorticoid drugs. For example, there is a strong cross-reactivity with the antibody used in this assay and dexamethasone which may result in a false elevation of cortisol. It is unknown how much of the reported result is the patient's endogenous cortisol, versus how much is cross-reactivity from the medication.

Genova's hormone assays measure endogenous hormones as well as bioidentical hormone replacement, but not synthetic hormones, due to their different molecular structure. Hydrocortisone is bioidentical cortisol and is prescribed for patients with adrenal insufficiency. Some studies suggest utility of salivary cortisol measurements for monitoring glucocorticoid replacement therapy, however studies are mixed.15

Shift Workers and Alternate Sleep-Wake Schedules

The reference ranges for the Adrenocortex Stress Profile (ASP) were designed for patients with normal sleep cycles and referenced for the specific time frames as graphed on the test report. However, some clinicians choose to test individuals with altered sleep cycles, knowing that the graph, and reference ranges may not directly apply. Even though the reference ranges may not apply, there is still some clinical information to be gleaned based on the overall slope of the diurnal curve. It is unknown whether extrapolating from the diurnal curve and reference ranges would apply to someone on an alternate schedule - "healthy" or "normal" has not been defined for this population.16-19 If the clinician chooses to test, the clinician can change the morning peak time to the patient's waking time (within one hour of waking) and then each additional sample will be approximately four hours after the prior.

In order to determine cortisol awakening response (CAR), samples must include both the waking and 30-minute samples. The timing of these collections should reflect when the patient wakes to begin their day. It has been shown in literature that patients who have alternate work schedules may 'reset' their internal circadian rhythm and, therefore, CAR sampling can be done during their normal waking cycle. When the patient wakes, have them immediately give a saliva sample, then another exactly 30 minutes later for CAR. These two samples are used for the CAR calculation. The third sample should be within that hour, then every four hours after that to complete the ASP portion.

Bleeding Gums

Samples visibly contaminated with blood should be recollected. This can result in a false elevation of hormones. Blood concentrations of steroid hormones are several-fold higher than saliva levels.20,21 For this reason, brushing and flossing is discouraged for 1 hour prior to salivary collection. Additionally, if the patient has a condition that causes gums to bleed easily, such as gingivitis or periodontitis, or has dentures and other oral appliances, a plan should be in place to ensure gums do not bleed during testing.

Pediatric Patients

The reference ranges for the Adrenocortex Stress Profile are based off a healthy cohort of patients aged greater than 18. Genova does not have pediatric reference ranges. DHEA is an androgen and is typically lower in prepubescent populations. A literature search may provide further insight into pediatric reference ranges for cortisol and DHEA.

 

References
  1. Pandya D, Puttanna A, Balagopal V. Systemic effects of inhaled corticosteroids: an overview. The Open Resp Med J. 2014;8:59-65.
  2. Sastre J, Mosges R. Local and systemic safety of intranasal corticosteroids. J Invest Allergol Clin Immunol. 2012;22(1):1-12.
  3. Baptist AP, Reddy RC. Inhaled corticosteroids for asthma: are they all the same? J Clin Pharm Therap. 2009;34(1):1-12.
  4. Stout A, Friedly J, Standaert CJ. Systemic Absorption and Side Effects of Locally Injected Glucocorticoids. PM & R : J Injury Function Rehab. 2019;11(4):409-419.
  5. Masharani U, Shiboski S, Eisner MD, et al. Impact of exogenous glucocorticoid use on salivary cortisol measurements among adults with asthma and rhinitis. Psychoneuroendocrinology. 2005;30(8):744-752.
  6. Habib GS. Systemic effects of intra-articular corticosteroids. Clinical Rheumatol. 2009;28(7):749-756.
  7. Broersen LH, Pereira AM, Jørgensen JO, Dekkers OM. Adrenal Insufficiency in Corticosteroids Use: Systematic Review and Meta-Analysis. J Clin Endocrinol Metab. 2015;100(6):2171-2180.
  8. Chon JY, Moon HS. Salivary cortisol concentration changes after epidural steroid injection. Pain Phys. 2012;15(6):461-466.
  9. Silver S, Tuppal R, Gupta AK, et al. Effect of calcipotriene plus betamethasone dipropionate topical suspension on the hypothalamic-pituitary-adrenal axis and calcium homeostasis in subjects with extensive psoriasis vulgaris: an open, non-controlled, 8-week trial. J Drugs Dermatol. 2013;12(8):882-887.
  10. Krupin T, Mandell AI, Podos SM, Becker B. Topical corticosteroid therapy and pituitary-adrenal function. Arch Ophthal. 1976;94(6):919-920.
  11. Sandhu SS, Smith JM, Doherty M, James A, Figueiredo FC. Do topical ophthalmic corticosteroids suppress the hypothalmic-pituitary-adrenal axis in post-penetrating keratoplasty patients? Eye. 2012;26(5):699-702.
  12. Ambrogio AG, Pecori Giraldi F, Cavagnini F. Drugs and HPA axis. Pituitary. 2008;11(2):219-229.
  13. Lipworth BJ. Systemic adverse effects of inhaled corticosteroid therapy: A systematic review and meta-analysis. Arch Int Med. 1999;159(9):941-955.
  14. Pelewicz K, Miśkiewicz P. Glucocorticoid Withdrawal-An Overview on When and How to Diagnose Adrenal Insufficiency in Clinical Practice. Diagnostics. 2021;11(4).
  15. Jung C, Greco S, Nguyen HH, et al. Plasma, salivary and urinary cortisol levels following physiological and stress doses of hydrocortisone in normal volunteers. BMC Endo Dis. 2014;14:91.
  16. Cannizzaro E, Cirrincione L, Mazzucco W, et al. Night-Time Shift Work and Related Stress Responses: A Study on Security Guards. Int J Environ Res Public Health. 2020;17(2).
  17. Lindholm H, Ahlberg J, Sinisalo J, et al. Morning cortisol levels and perceived stress in irregular shift workers compared with regular daytime workers. Sleep Dis. 2012;2012:789274.
  18. Li J, Bidlingmaier M, Petru R, Pedrosa Gil F, Loerbroks A, Angerer P. Impact of shift work on the diurnal cortisol rhythm: a one-year longitudinal study in junior physicians. J Occup Med Toxicol. 2018;13:23.
  19. Bostock S, Steptoe A. Influences of early shift work on the diurnal cortisol rhythm, mood and sleep: within-subject variation in male airline pilots. Psychoneuroendocrinology. 2013;38(4):533-541.
  20. Hofman LF. Human saliva as a diagnostic specimen. J Nutr. 2001;131(5):1621s-1625s.
  21. Granger DA, Taylor MK. Salivary bioscience: foundations of interdisciplinary saliva research and applications. Springer Nature; 2020.

How it Works

Consult Doctor

Your doctor will discuss your symptoms and help decide which test is right for you.

Many specimen collections can be completed from the privacy of your home.

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Activate Test

Collection packs can be dropshipped directly to your home and everything you need to begin testing is included.

Already have a collection pack? Activate your test and begin today.

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Collect Samples

Use a calendar to plan for your collection.

Follow instructions carefully and be sure to add important details about you and your specimens in the Activation portal.

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Ship to Lab

Ship your specimens using the prepaid FedEx materials provided.

Results are available online. Schedule time with your physician to review results and create a plan for your health.

FAQ

Review information on the Test Preparation tab above for details on how medications and supplements may impact this test.

We provide a variety of testing services, and some of them may or may not be covered by your insurance plan.

Once your physician has ordered a Genova Diagnostics test for you, you can submit the CPT codes for your test to your commercial insurance plan to determine coverage. For information about billing options, please visit the Billing Information page.

Support guides, charts, and additional aids can be found on the Support Materials tab. Additional educational materials can be found in our Learning Library.

Genova also offers complimentary Medical Education Consultations for healthcare providers. Schedule consults online by signing in to your myGDX account.