DUTCH test: what the dried urine hormone test measures and what the evidence shows

The DUTCH test is a home urine test for cortisol and other hormones, run by Precision Analytical, a laboratory in Oregon in the US. The name stands for Dried Urine Test for Comprehensive Hormones.¹ Instead of collecting urine in a container for 24 hours, you wet small strips of filter paper with urine at four set times across one day, let them dry and post them back.² The laboratory then measures free cortisol, cortisone and cortisol breakdown products by mass spectrometry.² It is a convenient way to sample urine across a day. The published studies show it agrees closely with ordinary urine tests in healthy adults, but they are small and come from the company itself, and no clinical guideline recommends the test for diagnosing any condition.

What the DUTCH test is

Precision Analytical sells several DUTCH panels, including DUTCH Complete, DUTCH Plus and Cycle Mapping, which between them report adrenal hormones, sex hormones and their breakdown products, and on some panels markers such as organic acids and melatonin.¹ DUTCH Plus adds saliva samples alongside the urine.² An adrenal-only panel is listed in the company's online shop, as in the table below.

The company's website is written mainly for practitioners. Its patient pages describe a route in which a practitioner orders the test after a consultation, the kit is posted to your home, and the practitioner reviews the results with you.³ This guide covers the cortisol measurements.

How the collection works

In the company's published validation study, participants collected urine on filter paper at four times in one day: immediately on waking, 2 hours after waking, between 4pm and 5pm before the evening meal, and at bedtime.² They soaked each strip either by passing urine onto it or by dipping it in a cup of urine for 5 seconds, then left the strips to dry for at least 24 hours.² The kit's own instructions set the exact times and what to avoid on collection days, and the current timing differs a little from the study; the table summarises it for the adrenal panel.

The appeal is practical. Dried strips are easier to handle and post than a 24-hour container, and four timed samples show the shape of the day rather than a single total.

What it measures

For cortisol, the test reports three kinds of result.

• Free cortisol and cortisone at each time point. Cortisone is an inactive form of cortisol. Together they show a daily pattern, and in the validation study the pattern of free cortisol in urine did not differ from the pattern in saliva samples from the same 68 people.²
• Cortisol breakdown products. Metabolites called alpha- and beta-tetrahydrocortisol and tetrahydrocortisone, which the company reports together as "metabolized cortisol".¹²
• The morning rise. The awakening response, the sharp rise in cortisol soon after waking, cannot be measured directly from four dried urine spots. The authors suggest the second morning sample as a possible stand-in, but describe direct measurement as an advantage of saliva. In their data, a first-morning urine sample and a saliva sample on waking showed no agreement at all (intraclass correlation 0.01).²

Some panels also report sex hormones, organic acids and melatonin.¹ Those fall outside this guide.

What the published evidence shows

Two validation studies have been published, both by Precision Analytical staff. The first, in 2020, was funded by the company.² The second lists the company's founder, president and owner and one of its employees as authors.⁴ Agreement is reported as an intraclass correlation, where 1 means perfect agreement.

• Dried against liquid urine. In 20 healthy adults, cortisol from dried strips agreed almost perfectly with the same urine measured as liquid: 0.99 for free cortisol, 0.97 for cortisone and 0.96 for total metabolites.²
• Four spots against a full 24-hour collection. In 28 healthy adults, the four-spot results agreed well with a standard 24-hour collection: 0.89 for free cortisol, 0.95 for cortisone and 0.92 for total metabolites.² For free cortisol this depended on correcting for creatinine; without that correction agreement was 0.69.²
• Sex hormones. The 2021 study, in 26 healthy adults, found agreement above 0.9 between four spots and a 24-hour collection for 14 of 17 reproductive hormone metabolites. Cortisol was not part of that analysis.⁴

So the dried-strip method is a reasonable way to collect urine. What the studies do not show is how well the test performs in people with adrenal or pituitary disease, or that it identifies any condition. The 2020 authors note that because their participants were healthy, the results cannot necessarily be applied to patients with disorders of the HPA axis, the hormone system that controls cortisol.² The studies are small, written by the company, and compare DUTCH with other urine methods rather than with diagnoses or health outcomes.

Where DUTCH stands in clinical guidelines

Doctors screen for Cushing's syndrome with a standard 24-hour urine collection, late-night saliva or a dexamethasone suppression test.⁵⁶ They diagnose adrenal insufficiency, including Addison's disease, with blood tests, the standard being the short Synacthen test.⁷ A dried-urine profile is not among these tests, and we found no clinical guideline that recommends the DUTCH test for diagnosing or monitoring a cortisol disorder.

If you have symptoms that could mean an adrenal condition, such as easy bruising, purple stretch marks and weight gain around the middle, or weight loss, dizziness on standing and darkening skin, see a doctor. Our guides to testing for Cushing's, testing for Addison's and the standard 24-hour urine test explain what to expect.

DUTCH and "adrenal fatigue"

Cortisol tests, including blood and saliva tests, are sometimes offered as a way to check for "adrenal fatigue", the idea that long-term stress wears out the adrenal glands.⁸ Precision Analytical's website does not use that term, although it lists "adrenal dysfunction" among the issues providers can investigate with DUTCH markers.¹

The Endocrine Society says there is no scientific proof that adrenal fatigue is a true medical condition, that no test can detect it, and that the tests offered for it are not based on scientific evidence.⁸ A systematic review that screened 3,470 articles and included 58 found results that conflicted almost systematically, and concluded there is no evidence that adrenal fatigue is an actual medical condition.⁹

This matters for two reasons. People with persistent tiredness may have a condition that does need treatment, such as adrenal insufficiency, depression or obstructive sleep apnoea. And the Endocrine Society warns that taking adrenal hormone supplements you do not need may stop your own adrenal glands working, which can put you at risk of a life-threatening adrenal crisis.⁸ If a DUTCH test is suggested to look for adrenal fatigue, it is worth asking what the result would change. See adrenal fatigue.

One day, not three months

Like any urine or saliva test, a DUTCH profile describes the day it was collected. That is useful for seeing the shape of a day, but cortisol varies a lot between days. Across three studies of healthy adults, about half the variation in daily saliva measures was day-to-day fluctuation,¹⁰ and weekly 24-hour urine results correlated at only r = 0.59 to 0.68 from one week to the next.¹¹ A single day's profile is a weak guide to your usual level.

If your question is about long-term cortisol, a hair test measures it more directly. Scalp hair grows about 1 cm a month and takes up cortisol as it grows, so a 3 cm sample reflects roughly the past three months,¹² and the same people's hair cortisol correlated at r = 0.84 from one month to the next.¹¹ Hair cannot show the shape of a day, and it is not a diagnostic test either: it is not in clinical guidelines, and experts say it still needs validating outside research settings.¹³ See hair cortisol vs the DUTCH test for a side-by-side comparison.