Ajax Harwood Clinic

Adrenal testing: should I be tested?

Last reviewed 2026-09-23Content vb5246725fa6b

Reference tool — not medical advice. Clinician judgement always required.

Adrenal insufficiency

Defined testing criteria

Also called: Addison's disease, primary adrenal insufficiency, secondary adrenal insufficiency, low cortisol, hypoadrenalism, adrenal crisis

Patients read about 'adrenal fatigue' online or hear it from an ND after a fatigue-focused visit, and want reassurance that a real, dangerous adrenal problem (Addison's disease) isn't being missed. Others arrive already worried because they are on long-term steroids or opioids and have heard these can suppress adrenal function.

Raises suspicion

• Unexplained weight loss
• Orthostatic hypotension or dizziness on standing
• Hyperpigmentation of skin creases, gums, or scars (primary adrenal insufficiency)
• Salt craving
• Low sodium or high potassium on bloodwork
• Unexplained hypoglycemia
• Chronic glucocorticoid use, including high-dose inhaled steroids, now being tapered or stopped
• Chronic opioid use
• Known pituitary disease or recent pituitary surgery or radiation
• Acute illness in a patient with any of the above, where the threshold to test and treat should be low

Does not raise suspicion

• Fatigue alone
• Low mood
• Poor sleep
• Brain fog
• Generalized aches
• 'Just feeling run down' without weight loss, dizziness, pigmentation change, or a predisposing exposure

Red flags

• Adrenal crisis: hypotensive shock, severe vomiting or abdominal pain, altered consciousness, or fever in a patient with known or suspected adrenal insufficiency. This needs emergency assessment and empiric steroid treatment without waiting for lab results.

Who to test

Patients with discriminating features above: Cortisol (serum, random or 8 AM) (Situation-specific)8 AM serum cortisol as the initial screen; a low value prompts formal ACTH (cosyntropin) stimulation testing (no TestSelect entry; specialist-directed)
Acutely unwell patient with predisposing factors for adrenal insufficiencySame-day assessment; consider empiric hydrocortisone before results if crisis is suspected (no TestSelect entry; emergency management, not an outpatient test decision)

More likely instead

• ME/CFS
• Depression
• Sleep & insomnia
• Sleep apnea
• dehydration or a medication effect for dizziness on standing
• Why am I tired? (for fatigue as the presenting complaint generally)

Counselling script

“If you have unexplained weight loss, dizziness on standing, skin darkening, salt cravings, or you've been on long-term steroids or opioids, an 8 AM cortisol is a reasonable first test. Without those features, fatigue alone doesn't point to adrenal insufficiency, and a cortisol test is unlikely to change management. If you become acutely unwell with vomiting, fainting, or severe weakness, that needs emergency assessment, not an outpatient test.”

Chart snippet (OSCAR-safe plain text)

Concern discussed, not tested

Concern re: adrenal insufficiency discussed.
Discriminating features: weight loss, orthostatic hypotension, hyperpigmentation, salt craving, hypoglycemia, chronic glucocorticoid or opioid exposure; absent.
Assessment: fatigue alone, low pre-test probability for adrenal insufficiency.
Plan: no cortisol testing at this time; discriminating features reviewed with patient.
Ref: Endocrine Society primary adrenal insufficiency guideline 2016.
Patient given info page: https://adrenal.ajaxharwoodclinic.com/patient
Revisit if: unexplained weight loss, dizziness on standing, skin darkening, salt craving, or new glucocorticoid or opioid use.

Testing ordered

Concern re: adrenal insufficiency discussed.
Discriminating features: weight loss, orthostatic hypotension, hyperpigmentation, salt craving, hypoglycemia, chronic glucocorticoid or opioid exposure; some present as noted in chart.
Assessment: findings warrant screening for adrenal insufficiency.
Plan: 8 AM serum cortisol ordered; ACTH stimulation test to follow if low.
Ref: Endocrine Society primary adrenal insufficiency guideline 2016.
Patient given info page: https://adrenal.ajaxharwoodclinic.com/patient
Revisit if: symptoms worsen, or vomiting or fainting develop before results are back, in which case seek urgent care.

Revisit if

• New or worsening unexplained weight loss
• Dizziness or fainting on standing
• Darkening skin
• Salt craving
• Starting or stopping long-term steroids or opioids
• Vomiting, severe weakness, or fainting: seek emergency care

References

1. Endocrine Society. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline (2016)Recommends diagnostic testing for primary adrenal insufficiency in all patients with indicative clinical symptoms or signs; basis for the discriminating-features approach and for treating adrenal crisis as an emergency
2. European Society of Endocrinology / Endocrine Society. European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and therapy of glucocorticoid-induced adrenal insufficiency (2024)At least 1% of the population on chronic glucocorticoid therapy is at risk of glucocorticoid-induced adrenal insufficiency, supporting it as a discriminating feature to ask about

Evidence notes

Adrenal crisis features (hypotensive shock, vomiting, abdominal pain, altered consciousness) are standard content of the Endocrine Society primary adrenal insufficiency guideline [1], but the specific crisis-feature list was not independently re-quoted in this batch beyond the on-file verbatim quote, which supports the broader testing recommendation; this physiology is confident but not separately sourced here. Opioid exposure as an Adrenal insufficiency risk factor is carried over from the linked Cortisol (serum, random or 8 AM) test record, which cites [1] for this; a dedicated opioid-induced-adrenal-insufficiency guideline was searched for and not found. The available literature on opioid-induced adrenal insufficiency is narrative-review level, not a formal society guideline, so this remains a minor evidence gap rather than a sourced claim. Tag rationale: A, not borderline. Primary and secondary adrenal insufficiency have defined biochemical diagnostic criteria (ACTH stimulation testing) and a validated clinical syndrome.

Cushing's syndrome

Defined testing criteria

Also called: Cushing syndrome, Cushing's disease, cortisol excess, hypercortisolism, high cortisol

Patients with obesity, metabolic syndrome, or who have researched 'high cortisol' online, sometimes after an ND-ordered salivary or urine cortisol panel, ask whether their weight gain, fatigue, or mood changes mean Cushing's syndrome. Others are worried after reading about cortisol and chronic stress.

Raises suspicion

• Easy bruising
• Facial plethora (a red, round face)
• Proximal muscle weakness, such as difficulty rising from a low chair or climbing stairs
• Wide violaceous (purple) striae
• Features unusual for age, such as osteoporosis or hypertension in a young adult
• An adrenal incidentaloma found on imaging done for another reason

Does not raise suspicion

• Obesity alone
• Metabolic syndrome
• Hypertension or type 2 diabetes alone, without the discriminating features above
• Fatigue or 'stress' alone
• Generalized weight gain without the features above

Red flags

• Rapid-onset or severe virilization, suggesting an androgen-secreting adrenal tumour: needs urgent referral
• Profound weakness with a rapid clinical course and low potassium, suggesting an ectopic ACTH source: needs urgent endocrinology referral

Who to test

Patients with discriminating features or an adrenal incidentaloma: Late-night salivary cortisol (single sample) (Situation-specific), 24-hour urine free cortisol (Situation-specific)Late-night salivary cortisol, 24-hour urine free cortisol, or a 1 mg dexamethasone suppression test (no TestSelect entry; typically ordered by or with specialist input) are the three first-line tests; any one is a reasonable start

More likely instead

• Obesity or metabolic syndrome without discriminating features
• Depression (for mood and weight change)
• Menopause (for weight redistribution)
• Diabetes

Counselling script

“If you have easy bruising, a red round face, muscle weakness getting up from a chair, wide purple stretch marks, or health issues unusual for your age, testing for Cushing's syndrome with a late-night saliva test, 24-hour urine, or dexamethasone suppression test is reasonable. Without those features, obesity or metabolic syndrome alone doesn't justify testing, and a random blood cortisol result, high or low, doesn't diagnose or exclude Cushing's syndrome.”

Chart snippet (OSCAR-safe plain text)

Concern discussed, not tested

Concern re: Cushing's syndrome discussed.
Discriminating features: bruising, plethora, proximal myopathy, violaceous striae, features unusual for age; absent.
Assessment: low pre-test probability; obesity or metabolic syndrome alone does not warrant screening.
Plan: no cortisol testing at this time.
Ref: Endocrine Society Cushing's syndrome guideline 2008; Pituitary Society consensus update 2021.
Patient given info page: https://adrenal.ajaxharwoodclinic.com/patient
Revisit if: bruising, facial changes, proximal weakness, or new striae develop.

Testing ordered

Concern re: Cushing's syndrome discussed.
Discriminating features: bruising, plethora, proximal myopathy, violaceous striae, features unusual for age; some present as noted in chart.
Assessment: findings warrant first-line testing for Cushing's syndrome.
Plan: late-night salivary cortisol or 24-hour urine free cortisol ordered; dexamethasone suppression test option discussed.
Ref: Endocrine Society Cushing's syndrome guideline 2008; Pituitary Society consensus update 2021.
Patient given info page: https://adrenal.ajaxharwoodclinic.com/patient
Revisit if: symptoms progress before results are back.

Revisit if

• New bruising, facial rounding, or purple striae
• New difficulty rising from a chair or climbing stairs
• Rapid onset of masculinizing features, such as a deepening voice or new facial hair: urgent referral

References

1. Endocrine Society. The Diagnosis of Cushing's Syndrome: An Endocrine Society Clinical Practice Guideline (2008)— older guidelineScreening for Cushing's syndrome should target patients with discriminating features, not obesity or metabolic syndrome alone; defines the three first-line tests
2. Pituitary Society. Consensus on diagnosis and management of Cushing's disease: a guideline update (2021)Consensus update from a multidisciplinary expert workshop, reaffirming the discriminating-features approach to diagnosis

Evidence notes

[1] is flagged older_than_10y (2008), but the 2021 Pituitary Society consensus [2] is cited alongside it and does not contradict the discriminating-features approach or the three first-line tests, so the guidance appears durable rather than superseded. Random serum cortisol is explicitly not a validated screening test for Cushing's syndrome, whether high or low (see the linked Cortisol (serum, random or 8 AM) test record); this matters because ND-ordered panels sometimes report a single cortisol value as though it settles the question either way. Tag rationale: A, not borderline. Cushing's syndrome is a well-defined syndrome with validated first-line diagnostic tests.

Popular labels: what they mean

"Adrenal fatigue"

Not a recognized medical diagnosis

Also called: adrenal fatigue, adrenal exhaustion, HPA axis dysfunction, adrenal burnout, tired adrenals, adrenal stress

'Adrenal fatigue' is a popular label, often introduced by an ND, a wellness blog, or social media, for the common experience of chronic tiredness, poor stress tolerance, and feeling 'wired but tired.' It borrows adrenal-gland language because cortisol is genuinely involved in the body's stress response, which makes the label feel biologically plausible even though it is not a recognized diagnosis. The tiredness and stress intolerance patients describe are real; the label attached to them is not.

Raises suspicion

• This label itself has no discriminating features, because it is not a defined diagnostic category. Features of true adrenal insufficiency (unexplained weight loss, orthostatic hypotension, hyperpigmentation, salt craving) or Cushing's syndrome (bruising, plethora, proximal myopathy, striae) should redirect assessment to those pages instead.

Does not raise suspicion

• Fatigue
• Feeling 'wired but tired'
• Poor tolerance of stress
• Low libido
• Brain fog
• Salt or sugar cravings
• Feeling worse after a stressful period
• A low DHEA-S or a 'flat' salivary cortisol curve reported on a wellness panel

Red flags

• None specific to this label. If red flags for adrenal insufficiency or Cushing's syndrome are present, redirect assessment to those pages.

Who to test

Everyone presenting with this concernNo test confirms or excludes 'adrenal fatigue' because it is not a defined diagnosis. Testing should target real conditions, such as adrenal insufficiency, Cushing's syndrome, hypothyroidism, sleep disorders, or depression, only when their own discriminating features are present.

More likely instead

• ME/CFS
• Sleep & insomnia
• Sleep apnea
• Depression
• iron deficiency (see the iron page)
• Hypothyroidism (see the thyroid page)
• Diabetes
• medication effects, shift work, or caregiving-related burnout
• Why am I tired? (for fatigue as the presenting complaint generally)

Counselling script

“'Adrenal fatigue' isn't a diagnosis recognized by endocrine specialists, and there's no validated test for it; salivary or urine cortisol panels marketed for this purpose haven't been shown to identify a treatable condition. If you have features of true adrenal insufficiency or Cushing's syndrome, we should test for those specifically. Without those features, let's look at the common, treatable causes of your tiredness instead.”

Chart snippet (OSCAR-safe plain text)

Concern discussed, not tested

Concern re: 'adrenal fatigue' discussed, raised by patient or ND.
Discriminating features for adrenal insufficiency or Cushing's syndrome: absent.
Assessment: 'adrenal fatigue' is not a recognized diagnosis; no validated test exists for it.
Plan: no adrenal panel ordered; alternative causes of fatigue and next steps discussed.
Ref: Endocrine Society adrenal fatigue patient statement; Cadegiani and Kater systematic review 2016.
Patient given info page: https://adrenal.ajaxharwoodclinic.com/patient
Revisit if: features of true adrenal insufficiency or Cushing's syndrome develop.

Revisit if

• Weight loss, dizziness on standing, skin darkening, or salt craving (adrenal insufficiency features)
• Bruising, facial rounding, muscle weakness, or new striae (Cushing's features)
• Symptoms significantly affecting daily function despite reassurance: reassess for depression, a sleep disorder, or another treatable cause

References

1. BMC Endocrine Disorders. Adrenal fatigue does not exist: a systematic review (2016)— older guidelineSystematic review concluding that 'adrenal fatigue' has not been recognized by any endocrinology society and that no hard evidence supports its existence
2. Endocrine Society (patient education). Adrenal Fatigue (2026)Endocrine Society patient-facing statement that there is no test that can detect adrenal fatigue

Evidence notes

Tag rationale: C, not borderline. Every major endocrine body reviewed rejects 'adrenal fatigue' as a diagnosis: the Endocrine Society's current patient page [2] and the Cadegiani and Kater systematic review of society positions [1] agree. [1] is flagged older_than_10y (2016), but its conclusion is reaffirmed by the current Endocrine Society patient page, so the guidance is not stale. Host is 'adrenal' (the subdomain landing page) rather than a single anchor condition, because 'adrenal fatigue' can be confused with either adrenal insufficiency or Cushing's syndrome depending on the patient's presentation, and the adrenal subdomain has no single anchor condition analogous to hypothyroidism on the thyroid page.

General clinical reference for Ajax Harwood Clinic. Not medical advice, and not a substitute for individualized clinical assessment.