Skip to main content
Intended for healthcare professionals
Free access
Review article
First published online January 28, 2009

Salivary steroid assays – research or routine?

Peter Wood [email protected]View all authors and affiliations
Volume 46, Issue 3
https://doi.org/10.1258/acb.2008.008208

Abstract

Salivary concentrations of unconjugated steroids reflect those for free steroids in serum although concentrations may differ because of salivary gland metabolism. Samples for salivary steroid analysis are stable for up to 7 days at room temperature, one month or more at 4°C and three months or more at −20°C. When assessed against strict criteria, the evidence shows that salivary cortisol in evening samples or following dexamethasone suppression provides a reliable and effective screen for Cushing's syndrome. Sequential salivary cortisol measurements are also extremely helpful for the investigation of suspected cyclical Cushing's syndrome. There is potential for the identification of adrenal insufficiency when used with Synacthen stimulation. Salivary 17-hydroxyprogesterone and androstenedione assays are valued as non-invasive tests for the home-monitoring of hydrocortisone replacement therapy in patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. The diagnostic value of salivary oestradiol, progesterone, testosterone, dehydroepiandrosterone and aldosterone testing is compromised by rapid fluctuations in salivary concentrations of these steroids. Multiple samples are required to obtain reliable information, and at present the introduction of these assays into routine laboratory testing is not justified.

Introduction

Salivary steroid measurements have the potential to provide a convenient and non-invasive assessment of serum ‘free’ steroid concentrations. They have widespread research applications in the fields of endocrinology, neuroendocrinology, sports and exercise science, and reproductive endocrinology. In spite of a large number of research publications and several reviews,1–3 salivary steroid methods have not been adopted by the majority of diagnostic laboratories.
This review discusses the factors which influence salivary steroid concentrations and assesses the diagnostic value of steroid measurements against a set of criteria which are appropriate for routine laboratory testing.

Overview – influencing factors

Mechanism of entry of steroids into saliva

Saliva is produced from three main pairs of salivary glands – the parotid, submaxillary and sublingual glands. The parotid glands consist of serous acinar cells which produce a serous, watery secretion, while the submaxillary glands consist of serous and mucous acinar cells and produce a mixed serous and mucous saliva. Sublingual gland saliva is predominantly mucous in character. In addition, 600–1000 minor salivary glands make a small contribution to total salivary production.
Saliva is formed by an active energy-consuming process in which sodium is pumped into the acinar end of the glands. The osmotic pressure difference between serum and saliva causes water to flow through the tight junctions of the acinar cells into saliva, so that the primary secretion into the duct is approximately isotonic with serum. As the saliva travels down the salivary gland duct, sodium is pumped back into the blood, and since little water is reabsorbed, the resulting saliva leaving the duct is hypotonic. The capacity of the ductal cells to pump sodium out of saliva is limited, and so the sodium concentration in secreted saliva is flow rate-dependent.
There are two main mechanisms by which steroids reach the saliva:

Intracellular diffusion

Serum components that are soluble in the lipid-rich cell membrane of the salivary gland acinar cells can pass freely into the cell and diffuse through into the saliva. This mechanism applies to lipid-soluble unconjugated steroids.
Since steroids in serum are protein-bound to a large extent, only the free, non-protein-bound unconjugated steroids will pass into saliva by the diffusion route.

Ultrafiltration

Together with water, non-protein-bound components of serum with a molecular weight of less than approximately 1900 kDa may pass between the tight junctions of the acinar cells. Small polar molecules such as steroid sulphate or glucuronide conjugates are restricted to this ultrafiltration route as a mode of entry into saliva.
As a consequence of these two different routes of entry for steroids into saliva, concentrations of salivary unconjugated steroids such as cortisol, oestradiol and testosterone reflect their free concentrations in serum, whereas conjugated steroids such as dehydroepiandrosterone sulphate (DHEAS) and oestriol sulphate are present in only 1% of their unbound serum concentrations.4
The two different mechanisms for entry of unconjugated and conjugated steroids into saliva also have important consequences in terms of the influence of salivary flow rates on salivary steroid concentrations. Unconjugated steroids such as salivary cortisol diffuse freely through the salivary gland acinar cells and show little change at low and high extremes of salivary flow rate.4 In contrast, a conjugated steroid such as DHEAS shows a marked fall in concentration with high salivary flow rates because of the rate-limiting ultrafiltration process (Figure 1).
Figure 1 Concentrations of cortisol and dehydroepiandrosterone sulphate in human parotid saliva at low- and high-saliva flow rates. Reproduced from Vining et al.4 with permission

Metabolism of steroids by salivary glands

Typical salivary concentrations of steroids are listed in Table 1.
Table 1 Typical salivary steroid concentrations
Salivary steroid Measured in Typical salivary concentration % of Total serum concentration
Aldosterone Healthy adults <150 pmol/L 30
Androstenedione Prepubertal Children 20–250 pmol/L 5
Adult men 140–630 pmol/L
Adult women 60–480 pmol/L
Cortisol Adults 08:00–10:00 h 6–30 nmol/L 5
Adults 22:00 h to midnight <5 nmol/L
Cortisone Adults 08:00–10:00 h 20–80 nmol/L approximately 100
Adults 22:00 h to midnight 3–14 nmol/L
Dehydroepiandrosterone Men 0.3–1 nmol/L 5
Women (pre-menopause) 0.3–1.7 nmol/L
Oestradiol Women –follicular phase 2–20 pmol/L 1–2
-mid-cycle 10–30 pmol/L
17α-hydroxyprogesterone Prepubertal children 25–220 pmol/L 3–4
Men 50–360 pmol/L
Women (luteal phase) 140–320 pmol/L
Progesterone Women –follicular phase <160 pmol/L 2
-luteal phase 200–1600 pmol/L
Testosterone Men (am) 250–600 pmol/L 1–2
Women <200 pmol/L
5α-dihydrotestosterone Men 30–150 pmol/L 5
Women (pre-menopausal) 6–25 pmol/L
These are consensus values taken from the literature. They are illustrative values only. Reference ranges will vary with the methods used
The salivary glands have the capacity to metabolize steroids, and so although there is correlation between salivary and serum free steroid concentrations, the concentrations in saliva and serum may differ.
Salivary concentrations of cortisol are only 50–60% of the corresponding serum free cortisol concentration, while salivary cortisone concentrations are higher than those for cortisol. Serum total cortisol:cortisone ratios are approximately 8:1, while the salivary cortisol:cortisone ratio is approximately 1:4 with a range from 1:2 to 1:8. This marked contrast in serum and salivary cortisol:cortisone ratios results from two main effects.
First, cortisol-binding globulin (CBG) in serum binds cortisone less strongly than cortisol, with an association constant 10 times lower for cortisone than for cortisol. Therefore, the proportion of free cortisone in serum is much higher than that for cortisol, and this is reflected in the steroid concentrations reaching saliva.
Secondly, the salivary glands are mineralocorticoid target glands and contain the enzyme 11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2).5 This enzyme converts cortisol to cortisone irreversibly and protects mineralocorticoid receptors from the influence of cortisol. 11β-HSD2 converts some cortisol to cortisone as it passes through the salivary gland and therefore contributes to the higher concentrations of cortisone in saliva.
In the case of progesterone, salivary concentrations are approximately one-fiftieth of those in serum. The salivary glands, particularly the submandibular glands, can metabolize this steroid to 20α-hydroxy-4-pregnen-3-one.6 The extent of progesterone metabolism is minor, and because of the rapid transit of progesterone into saliva from blood it is not considered to be an important influence on salivary progesterone concentrations.
Studies on the metabolism of androstenedione (AD) and testosterone by salivary glands indicate presence of the enzyme 17β-hydroxysteroid dehydrogenase (17βHSD, also known as 17-hydroxysteroid oxido-reductase). In women, relatively high salivary testosterone concentrations compared with serum free concentrations are consistent with conversion of AD to testosterone by salivary glands.7,8 For men, salivary testosterone concentrations are lower than the corresponding serum free results, which could be explained by salivary gland conversion of testosterone to AD.6,7
17βHSD in the parotid glands has been shown to favour an oxidative reaction in the conversion of oestradiol to oestrone.9 The fact that salivary and serum free oestradiol concentrations are similar suggests that oestradiol metabolism has relatively little influence on salivary oestradiol results.

Correlation of salivary steroid concentrations with serum total or free steroid results

In general, studies comparing salivary and serum total or free steroid concentrations show highly significant correlations with correlation coefficients (r) greater than 0.8 (Table 2). Exceptions are the relatively poor correlations with serum free testosterone for females reported by Broadbent10 (r = 0.42) and Granger et al.11 (r = 0.36).
Table 2 Systematic survey of correlations between salivary and serum steroid concentrations
Salivary steroid Correlated with r value Reference
Aldosterone Serum total 0.96 McVie et al.67
Serum total 0.92 Hubl et al.99
Serum total 0.93 Atherden et al.68
Serum free 0.84 Few et al.70
Serum total 0.75 Few et al.70
Androstenedione Serum total 0.92 Baxendale et al.66
Serum total 0.97 Otten et al.60
Cortisol Serum total 0.97 Riad-Fahmy et al.100
Serum free 0.97 Vining et al.12
Serum total 0.93 Vining et al.12
Serum total 0.96 Luthold et al.101
Serum total 0.85 Gallagher et al.102
Dehydroepiandrosterone Serum total 0.87 Granger et al.73
Serum total 0.86 Ahn et al.74
5α-Dihydrotestosterone Serum free 0.82 Baxendale et al.66
17α-Hydroxyprogesterone Serum total 0.97 Price et al.103
Serum total 0.94 Otten et al.60
Serum total 0.93 Zerah et al.57
Bloodspot total 0.81 Porcu29
Oestradiol Serum total 0.82 Worthman et al.104
Serum total 0.78 Wang et al.105
Serum total 0.71 Lu et al.106
Oestriol Serum total (unconjugated) 0.97 Vining et al.84
Serum total (unconjugated) 0.90 Lachelin and McGarrigle107
Progesterone Serum total 0.88 De Boever et al.108
Serum total 0.99 Bolaji109
Serum total 0.75 Lu et al.110
Testosterone Serum free 0.79 Baxendale et al.66
Serum free 0.97 Vitek et al.111
Serum total 0.7–0.87 Vitek et al.111
Serum free (women) 0.42 Broadbent10
Serum free (men) 0.78 Broadbent10
Serum free (women) 0.36 Granger et al.11
For cortisol, there is strong evidence that serum total and free concentrations correlate with salivary cortisol in a predictable manner. The data of Vining et al.12 clearly show that there is a biphasic response in salivary cortisol when plotted against serum total concentrations (Figure 2). Once the binding capacity of CBG in serum of approximately 600 nmol/L cortisol is exceeded, salivary cortisol concentrations increase more rapidly with increasing total cortisol concentrations, reflecting a disproportionate increase in serum free cortisol. Pregnancy samples, which contain higher CBG concentrations, show a continuation of the initial correlation up to higher serum total cortisol concentrations, as expected. When serum free and salivary cortisol concentrations are compared (Figure 3), a linear relationship is seen over the whole range of serum free cortisol results.12
Figure 2 Cortisol concentration in time-matched samples of serum and saliva from normal men, normal women, women on oral contraceptives and pregnant women. Reproduced form Vining et al.12 with permission
Figure 3 Relationship between salivary cortisol and serum unbound cortisol concentrations in time-matched samples of saliva and serum. Reproduced from Vining et al.12 with permission
Further evidence of the validity of salivary cortisol measurements is provided by the data of Hofman,1 who compared average serum cortisol results over 4 h with cortisol concentrations in a 4-h saliva collection using the oral diffusion sink (ODS) device. A correlation coefficient of r = 0.96 was found.
Evidence of good serum vs. saliva correlation for steroid studies, although reassuring, does not necessarily imply that salivary measurements are suitable for routine diagnostic use. For oestradiol, progesterone and testosterone for example, there is evidence that rapid fluctuations in salivary concentrations may detract from their routine use compared with a single serum estimation despite the good overall correlations found (for details, see sections on individual steroids below).

Collection, storage and stability of salivary steroid samples

Saliva collection devices

Whole saliva is a mixture of saliva from the major salivary glands – the parotid, submandibular and sublingual glands – and other minor glands. Other components can include gingival crevicular fluid, serum and blood from oral wounds, bacteria and bacterial products, viruses and fungi, desquamated epithelial cells and food debris.
Parotid saliva can be obtained using a Carlson–Crittenden cup placed over the Stensen's duct. This device, described by Shannon et al.13 consists of two small concentric cups, each with a tube attached. Suction is applied to the outer cup to hold the device in place, and saliva is collected through the inner cup. However, this procedure is not convenient for routine diagnostic use.
Most studies of salivary steroids involve collection of mixed saliva obtained by direct spitting into a suitable tube, or by chewing on a wad of absorbent material.
Polyethylene collection tubes should be avoided, since they may adsorb steroids,14 and the use of polypropylene tubes, which minimize steroid adsorption problems is preferable.
A variety of saliva collection methods have been used. It is important to ensure that any collection method used does not compromise the salivary steroid measurements.
Wade and Haegle15 described an oral diffusion sink device consisting of a tiny plastic tube containing cyclodextrin to bind analytes. This allowed the collection of saliva over a period of several hours.
Polypropylene ‘Salicaps’ and straws have been developed by one commercial kit supplier (IBL-Hamburg), to give an adsorption of <5% for unconjugated steroids.
‘Salivettes’ (Sarstedt Ltd) offer a convenient means of saliva collection, and consist of an upper chamber with a removable wad which is chewed. The wad is replaced in the upper chamber, and at a later stage the sample can be frozen and thawed, and the tube centrifuged to obtain a clear sample in the conical lower section of the device. Although the use of Salivettes with a cotton wad is acceptable for cortisol, results for dehydroepiandrosterone (DHEA), testosterone, progesterone and oestradiol are spuriously high. This is probably due to the presence of plant sterols in the cotton, which cross-react in steroid immunoassays.16 These effects are illustrated in Figure 4.
Figure 4 Saliva collection using ‘Salivettes’ with a cotton wad: effects on measured salivary steroid concentrations compared with collection without a wad. Figure derived from the data of Shirtcliff et al.16 **Denotes results which were significantly greater than the unsystematic error in the assay performance (P < 0.005). NS = not significant
Salivettes with cotton wads should be avoided for steroids other than cortisol. For the collection of other steroids, Salivettes with the cotton wad removed, or with a polypropylene wad17 can be used, or saliva can be collected into a polypropylene microcentrifuge tube.
The use of a short plastic straw can be helpful for children, and recently the use of mini-marshmallows was very successful for the collection of salivary cortisol samples from toddlers.18 For very young infants, saliva may be collected with a plastic ‘Pasteur’ pipette.
The use of citric acid or lemon juice to stimulate salivary flow can cause problems with steroid analysis 19 and should be avoided. Chewing on unflavoured chewing gum has been used for saliva collection but offers no real advantages.

Stability of steroids in saliva

Storage of saliva samples at room temperature for more than 7 d can result in deterioration caused by bacterial growth,20 although this effect is reduced if cellular debris is removed by centrifugation prior to storage.21,22
Clements and Parker23 found no difference in salivary cortisol concentrations between aliquots frozen immediately and those subjected to temperature and movement changes to simulate postal delivery over a period of 5 d. Postal delivery of saliva samples to the laboratory is therefore acceptable provided that these are frozen on receipt.
In general, samples for salivary steroid analysis are stable for up to 1 month at +4°C, and for up to 3 months at −20°C. For salivary cortisol, centrifuged saliva samples have been shown to be stable for up to 3 months at +5°C and 1 year at −20°C or −80°C22 and uncentrifuged samples were stable for 9 months at −20°C.24
Freezing of samples is necessary for long-term storage, but in addition, freezing and thawing of saliva prior to analysis is necessary to break up the viscous saliva matrix and to obtain good recovery of steroids.
Salivary steroid concentrations are relatively stable through four or five freeze/thaw cycles. Groschl et al.21 for example showed that 17α-hydroxyprogesterone and progesterone decreased by only 5% through five freeze/thaw cycles, while cortisol decreased by 10%. Garde and Hansen22 found that cortisol concentrations in centrifuged saliva samples were unaffected by four freeze/thaw cycles.

Precautions for saliva collection

The effect of vigorous tooth-brushing on salivary cortisol and testosterone has been studied by Kivlighan et al.25 Haemoglobin and transferrin assays confirmed the presence of blood in saliva samples for 30 min after tooth-brushing. Salivary testosterone was increased for 30 min, although the effects on cortisol were minor. Groschl et al.21 did not find a significant increase in salivary cortisol, 17α-hydroxyprogesterone (17-OHP) or progesterone 5 min after ‘dental care’.
As a general precaution when collecting saliva for steroid analysis, samples should not be collected within 30 min of tooth-brushing or using dental floss.
In addition, to minimize contamination of saliva, samples should not be collected within 30 min of eating, drinking or chewing ordinary (flavoured) chewing gum.

The influence of blood contamination

Salivary/serum steroid ratios are approximately 1:20 for cortisol and 1:90 for testosterone and oestradiol, and so contamination of saliva with blood can result in spurious increases in the measured steroid concentrations.
Visual inspection of saliva samples will detect a pink colouration at a concentration of 0.1–0.2% ( by volume) contamination with blood. If blood contamination cannot be detected by visual inspection, then the risk of contamination is small for cortisol measurements. For example, at a visible detection limit of 0.2% blood the salivary cortisol result would be overestimated by 4%. For testosterone and oestradiol, the corresponding overestimation would be in the region of 20% because of the higher serum/salivary concentration ratio for these steroids.
Studies that used haemoglobin and transferrin measurements to assess blood contamination in saliva samples from adults25 and children26 have confirmed that interference due to blood contamination is rare for salivary cortisol measurements, but may be of more importance for salivary testosterone and oestradiol testing.
To avoid these problems it is advisable to check saliva samples for any visible pink colouration and to reject any samples which are positive. A dipstick test for haemoglobin such as ‘Hemastix’ will give a positive result at 0.2–0.3% contamination by volume, and can be used to check samples.

Methods for salivary steroid analysis

Salivary steroid assay kits are available from several manufacturers (Table 3). These are usually microtitre plate format assays using enzyme immunoassay or chemiluminescence immunoassay technology.
Table 3 Salivary steroid assay kits
Manufacturer Supplier website Steroids
American Laboratory Products Co. www.alpco.com;www.diagenics.co.uk Cort, E2, P, 17OHP, T
Cambridge Bioscience www.bioscience.co.uk Cort, DHEA, E2, P,
Diametra www.diametra.com Cort, AD, E2, 17OHP, P, T
IBL-Hamburg www.IBL-Hamburg.com Cort, DHEA, E2, E3, 17-OHP, P, T
IDS Ltd www.idsltd.com Cort, E2, 17OHP, P, T
Salimetrics www.salimetrics.com Cort, AD, DHEA, E1, E2, E3, 17OHP, P, T
Cort, cortisol; AD, androstenedione; DHEA, dehydroepiandrosterone; E1, oestrone; E2, oestradiol; E3, oestriol; 17OHP, 17α-hydroxyprogesterone; P, progesterone; T, testosterone
The reagent cost for a salivary cortisol assay using commercial kit reagents is approximately £4. The use of salivary cortisol to screen for Cushing's is therefore cost-effective, with costs comparable with that of a urine cortisol, and considerably cheaper than serum cortisol tests with associated costs of venepuncture.
It is also possible to develop in-house assays for salivary steroids. Methods need to be designed to detect the much lower concentration of steroids in saliva. For example, a detection limit of 1 nmol/L or less is desirable for a salivary cortisol assay compared with detection limits of 20–30 nmol/L for serum assays. It is also important to assess antiserum cross-reactivity with a knowledge of the relative concentrations of steroids in saliva. Since there are much higher concentrations of cortisone in saliva, when designing a salivary cortisol assay it is necessary to use an anti-cortisol antibody with low cross-reactivity to cortisone to minimize interference.
In the author's experience, the Dissociation-Enhanced Lanthanide Fluorescence ImmunoAssay (DELFIA) time-resolved fluorescence principle can be used to develop robust and convenient in-house salivary steroid assays. Steroid oxime derivatives can be biotinylated using the reaction described by Dressendorfer et al.27 and the products can be purified by thin-layer chromatography. Streptavidin can be labelled with Europium to provide a common detection system for bound steroid-biotin tracers. This system has been applied successfully to the development of direct assays for salivary cortisol and cortisone,28 and, following ether extraction, to the assay of salivary 17-OHP.29
Liquid chromatography/tandem mass spectrometry (LC-MS/MS) is now being used more frequently for serum and salivary steroid analysis.
Baid et al.30 evaluated radioimmunoassay and LC-MS/MS for the measurement of bedtime salivary cortisol in 261 obese subjects and 60 healthy volunteers. Reference ranges for evening salivary cortisol determined for each method were <2.8 nmol/L for the LC-MS/MS assay and 1.4–4.7 nmol/L for the radioimmunoassay. When results were interpreted relative to the appropriate reference range as a screen for Cushing's syndrome, the two methods showed similar false-positive rates for non-obese normal subjects. However, for the 156 obese subjects who had results for both analyses, significantly more were classified as abnormal by the radioimmunoassay (RIA) (22/156; specificity 86%) than by LC-MS/MS (10/156; specificity 94%).
More studies are needed to confirm these results, which suggest that LC-MS/MS methods may give fewer false-positives when used to screen obese patients.
At present there are no National External Quality Assurance Schemes for salivary steroids, although a free quality assurance scheme for salivary cortisol, oestradiol, progesterone, testosterone and DHEA is provided by IBL-Hamburg. Two distributions, each of three samples are provided per year and mean and range of results returned can be viewed on the IBL website (www.IBL-Hamburg.com).

Routine diagnostic value of salivary steroid testing

Criteria for the assessment of salivary steroid analysis for routine diagnostic use

When examining the value of salivary steroid testing for use in routine clinical biochemistry laboratories it is helpful to establish some strict criteria against which the evidence in the literature can be assessed.
For diagnostic salivary steroid testing it is proposed that the following criteria should be met:
1.
There must be a constant and predictable correlation between salivary and serum free steroid concentrations;
2.
The diagnostic accuracy of salivary tests must be at least equal to that for serum or urine steroid determinations;
3.
Single saliva samples should be just as informative as single serum samples.

Salivary cortisol

There is a considerable body of evidence to support the introduction of salivary cortisol as a routine diagnostic test. Strong correlations between salivary and serum free or total cortisol have been reported (Table 2). Salivary cortisol values correlate in a predictable manner with total serum cortisol, allowing for cortisol-binding by CBG (Figure 2), and show a constant relationship to serum free cortisol concentrations (Figure 3).
Dorn et al.31 compared salivary and serum cortisol circadian rhythms by collecting hourly samples over 24 h. They concluded that the two profiles were synchronous, and that salivary cortisol could be substituted for serum cortisol for the assessment of circulating cortisol rhythmicity.
The majority of publications on the diagnostic use of salivary cortisol relate to screening for Cushing's syndrome using evening samples and/or the low-dose dexamethasone suppression test, with fewer reports on the investigation of adrenal insufficiency and the monitoring of hydrocortisone replacement therapy.

Screening for Cushing's syndrome

Currently, the three main screening tests for Cushing's syndrome are the assessment of diurnal rhythm in serum cortisol, morning serum cortisol following the low-dose overnight dexamethasone suppression test and the measurement of 24-h urine cortisol. All these tests have limitations; midnight serum cortisol measurements are only feasible for hospital inpatients, and 24-h urine collections are often unreliable. Some patients with mild Cushing's syndrome may suppress normally to the low-dose dexamethasone suppression test.32 In addition, the stress of hospital admission may cause abnormal adrenal axis test results for the first few days.33
Salivary samples can be collected in a relatively stress-free environment at home, and samples can be posted to the laboratory for analysis. They are particularly useful to document cyclical or intermittent changes in cortisol secretion over long-time periods where the collection of multiple urine samples is impractical.
There are now more than 10 published studies in adults and children that confirm that evening salivary cortisol can be used as a reliable screen for Cushing's syndrome. Although the time chosen to assess evening concentrations varies from 22:00 h to 24:00 h, the evidence suggests that the diagnostic value at these times is the same. Where figures for sensitivity and specificity have been quoted, these are generally in the range of 90–100% (Table 4) and compare favourably with those found for 24-h urine cortisol measurements34,35 and for serum cortisol assay following low-dose dexamethasone suppression.34
Table 4 Salivary cortisol as a screen for Cushing's syndrome: a systematic survey of the literature
Reference Sensitivity/Specificity (%)
Evening saliva LDDST Combined
Barrou et al.112 – 100/94 –
Raff et al.113 92/95 – –
Castro et al.114 93/93 91.4/94.4 100/93.3
Martinelli et al.115 100/95.2 100/95.2 100/100
Papanicolaou et al.38 93/100 – –
Putignano et al.39 92.7/93.1 – –
Yaneva et al.116 100/96 – –
Trilck et al.117 100/97.6 – –
Viardot et al.34 100/100 100/77.1 –
LDDST, low-dose dexamethasone suppression test
Salivary cortisol samples collected after low-dose dexamethasone suppression also show high sensitivity and specificity as a screen for Cushing's syndrome, and when used in combination with an evening salivary cortisol test, a sensitivity of 100% can be achieved (Table 4).
The day-to-day reproducibility of salivary cortisol measurements has been assessed by Viardot et al.34 and was found to be high with 78% of the total variation explained by inter-subject variation and 22% by intra-subject variation.
Salivary cortisol measurements are becoming more widely used as a screen for Cushing's syndrome, and recently they have been recommended as a first-line screening test by Findling and Raff.36 These authors recommend a 23:00 h salivary cortisol as an initial screen, using a cut-off of 4.3 nmol/L for normality. Any results over 8.6 nmol/L were considered to be consistent with Cushing's syndrome, while results between 4.3 nmol/L and 8.6 nmol/L generated a repeat 23:00 h salivary cortisol sample.
It is important that each laboratory establishes its own cut-off values for evening salivary cortisol, particularly when in-house or modified commercial methods are used, since results vary with different immunoassay methods. Typical cut-off values reported for normal evening salivary cortisol measured by immunoassay are in the range of 4–6 nmol/L. Reference ranges using chromatography and tandem mass spectrometry are often lower than those obtained by immunoassay methods.
In the author's laboratory, the screening procedure for Cushing's syndrome involves the collection of 08:00–10:00 h and 22:00 h to midnight saliva samples over 3 d. Reference ranges are 6–30 nmol/L at 08:00–10:00 h and <5 nmol/L at 22:00 h to midnight, and so evening results over 5 nmol/L are abnormal. This approach has been valuable in screening for Cushing's syndrome in women with polycystic ovaries and hyperandrogenism.37
As with all biochemical testing for Cushing's syndrome, there are limitations to the evening salivary cortisol test. It is important to establish that patients have a normal sleep/wake cycle when interpreting results, and that samples were taken at the right time if collected at home. Patients with ‘pseudo-Cushing's’ due to alcohol abuse, type 2 diabetes or major depression will give positive results.38,39
During pregnancy, salivary cortisol concentrations rise in the second and third trimesters, showing a 1.5–2-fold elevation, and fall back to normal within 5–7 d of parturition. A ‘lag’ of approximately 90 min in the salivary cortisol circadian rhythm in pregnancy has also been documented.40
Mild cases of Cushing's syndrome may show a normal evening salivary cortisol when tested on a single occasion. Kidambi et al.41 studied 11 cases of Cushing's syndrome with normal or mildly elevated urine cortisol. Although all patients had some elevated evening salivary cortisols, results were normal on some occasions, indicating that several saliva and urine samples and a dexamethasone suppression test are necessary for the thorough investigation of mild Cushing's syndrome.
Despite these limitations, the evidence suggests that for screening Cushing's syndrome, a single saliva sample taken in the evening or following low-dose dexamethasone suppression can be just as informative as a single blood sample.

Cyclical Cushing's syndrome

Cyclical or intermittent Cushing's syndrome may be more common than was thought. Evidence for this was provided by Atkinson et al.42 who studied nine of 14 consecutive patients diagnosed with Cushing's syndrome using multiple urine cortisol collections. They found that five of the nine patients studied showed cyclical variation in cortisol secretion, with a further two patients showing an erratic pattern without any obvious cyclicity.
The periodicity of cyclical Cushing's disease has been reported to vary between 12 h and 85 d. This makes diagnosis using conventional urine collections very difficult, particularly since ideally it is necessary to identify at least three peaks and two troughs in cortisol secretion.43
Salivary testing is an excellent screening test for cyclical Cushing's syndrome since it is non-invasive, convenient and can be undertaken over many days if necessary. For example, Laudat et al.44 measured 20:00 h salivary cortisol twice-weekly over a period of 60 d to establish Cushing's syndrome in a patient who showed a cyclicity of 21 d.
Salivary cortisol measured at Southampton in samples collected at 09:00 h and 22:00 h over 19 consecutive days at King's College Hospital were helpful in identifying food-dependent Cushing's syndrome in a patient whose evening saliva cortisols were often higher than those at 08:00 h (unpublished data).

Differential diagnosis of Cushing's disease

Castro et al.45 have studied salivary cortisol suppression to different doses of dexamethasone and the responses to ovine-corticotrophin releasing hormone (o-CRH) stimulation in 46 patients with Cushing's syndrome, including 28 patients with Cushing's disease. Salivary cortisol showed a higher percentage of suppression to dexamethasone than serum cortisol, with suppression of 65% or more for salivary cortisol corresponding to a suppression of serum cortisol of 50% or more for the 8 mg test. Sensitivities and specificities using salivary cortisol for the diagnosis of Cushing's disease were 88% and 100% for the 8 mg dexamethasone test and 93% and 91% for the o-CRH test (using a criterion of an increment >20%).
Salivary cortisol measurements may therefore improve the discrimination of the high-dose dexamethasone suppression test for the differential diagnosis of Cushing's disease. The evidence provided by future studies would be useful to confirm these findings.

Testing for adrenal insufficiency

There are fewer studies on the application of salivary cortisol testing to the investigation of adrenal insufficiency, but there is some evidence that morning salivary cortisol may be helpful in checking for adrenal suppression, and that salivary cortisol responses to Synacthen may be a useful test of adrenal function.
Patel et al.46 compared morning salivary cortisol results with serum cortisol concentrations from the conventional short Synacthen test (SST) to check for adrenal suppression in 48 patients who were using topical steroids. Of the 48 patients, 16 had an impaired morning salivary cortisol result, and of these, 15 had an impaired response to the SST. All patients with a normal morning salivary cortisol had a normal SST response. The authors concluded that morning salivary cortisol was efficient and cost-effective for outpatient screening of adrenal suppression due to glucocorticoid use.
Salivary cortisol responses to Synacthen have been evaluated for the conventional dose of 250 μg and also for reduced doses of 25 μg or 1 μg Synacthen.
Suri et al.47 used a 250 μg Synacthen test to assess adrenal reserve in pregnancy, and established reference ranges for the higher salivary cortisol responses seen in the second and third trimesters of pregnancy compared with postpartum results.
Basal and post-Synacthen (250 μg) serum total and free cortisol and salivary cortisol were measured by Arafah et al.48 in 51 critically ill patients and normal subjects. They found that serum free and salivary cortisol results correlated well and were uninfluenced by large differences in serum albumin concentrations. Salivary cortisol could be used as a surrogate marker for serum free cortisol for these investigations.
Contreras et al.49 found that a 25 μg Synacthen test gave equivalent serum and salivary cortisol responses to the 250 μg test at 30 min, with normal responses of >20 nmol/L and >100 pmol/L for salivary cortisol and aldosterone, respectively. The same research group went on to apply the 25 μg test with salivary samples to check for adrenal insufficiency in patients with HIV50 and patients with end-stage renal failure.51
A 1-μg low-dose Synacthen test was used by Marcus-Perlman et al.52 to assess responses in 14 normal subjects and 14 women who were ‘hyperoestrogenic’ (pregnancy, oral contraceptive or hormone replacement therapy). A normal salivary cortisol response of >27.6 nmol/L at 30 min was established, and the test was found to provide a useful alternative to the blood test, particularly when increased CBG concentrations complicated the interpretation of changes in serum total cortisol results.
The use of salivary sampling with the SST therefore has potential, but more studies are needed to establish its value in routine diagnostic testing.

Monitoring of glucocorticoid replacement therapy

The evidence on the value of salivary cortisol measurements for the assessment of glucocorticoid replacement therapy is conflicting.
Measurement of a daytime serum cortisol profile has been considered to be the best way of assessing replacement therapy, but this requires hospital admission.
Two groups have concluded that salivary daytime profiles are not useful for monitoring oral hydrocortisone, largely based on their observations of poor correlations between serum total and salivary cortisol results.53,54
In contrast to these reports, Lovas et al.55 found excellent correlation between salivary cortisol and serum cortisol profiles after oral cortisone acetate or intravenous hydrocortisone dosing. The same research group then used salivary cortisol measurements in combination with continuous subcutaneous hydrocortisone infusion in patients with Addison's disease to establish a more physiological cortisol rhythm.56
The finding of poor overall correlation between serum total cortisol and salivary cortisol in combined results for pre- and postdose samples could be explained by the disproportionate increase in serum free and salivary cortisol compared with serum total cortisol, once the binding capacity of CBG of approximately 600 nmol/L cortisol is exceeded. This happens frequently after oral hydrocortisone administration in standard doses. An example of increases found in our laboratory (unpublished data) following a 10 mg dose of hydrocortisone in the morning are from 1 nmol/L to 63.5 nmol/L for salivary cortisol (a 64-fold increase) and from 49 nmol/L to 734 nmol/L for serum total cortisol (a 15-fold increase). Salivary samples were collected at least 30 min after taking the oral hydrocortisone dose.
There is no reason why the serum total cortisol profile should be taken as the ‘gold standard’, and it is possible that salivary cortisol, which reflects the biologically active serum free cortisol concentration, may provide a more useful measurement of replacement therapy provided that problems of saliva contamination by the hydrocortisone tablets are avoided.

Salivary 17α-hydroxyprogesterone

Salivary 17-OHP measurements have been applied to screening for classical and non-classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency, and to the monitoring of hydrocortisone replacement therapy in CAH patients.
Zerah et al.57 measured serum and salivary 17-OHP in 57 normal subjects and 15 newly diagnosed patients with non-classical 21-hydroxylase deficiency. They found good correlation between serum and salivary results (r = 0.93) and morning salivary 17-OHP concentrations were unequivocally higher in all patients compared with normal subjects. The salivary test was found to be convenient and effective, and was used in a second study to establish a prevalence of non-classical 21-hydroxylase deficiency of 1.4% in a Caucasian population.58,59
Studies on the use of salivary 17-OHP assays to monitor patients on hydrocortisone replacement therapy have all found the procedure to be convenient and helpful, although there are large differences in reference ranges found for normal subjects and for patients in good control.29,60–64 These discrepancies may be due to differences in antiserum specificity and to the fact that some methods do not employ a preliminary solvent extraction stage prior to immunoassay.
At Southampton, UK, we have developed an in-house time-resolved fluorescence assay for salivary 17-OHP using ether extraction followed by immunoassay.29 The method proved to be a convenient means of assessing control in children with 21-hydroxylase deficiency. Results showed a good correlation with those for bloodspot 17-OHP samples taken at the same time (r = 0.81) with good day-to-day reproducibility. Morning salivary 17-OHP concentrations of 25–217 pmol/L found for normal children agreed well with the range of 6–225 pmol/L reported by Groschl et al.64 although other groups have reported higher morning reference ranges.60,61,63
Children with CAH on replacement therapy, classified as having good control, had morning salivary 17-OHP concentrations in the range of 390–3090 pmol/L, falling to <1500 pmol/L later in the day. These results agree with those of Otten et al.60 who found a morning range of 340–3060 pmol/L in patients with good control. However, a lower target range of <1000 pmol/L was reported by Young et al.62
Method-related differences in salivary 17-OHP results make it essential for a laboratory to establish reference ranges and target ranges for treated patients with the particular method used.
The evidence suggests that salivary 17-OHP measurements have a place as a convenient and non-invasive means of monitoring control in CAH patients while at home.

Salivary androstenedione

Salivary AD measurements have been evaluated for the monitoring of replacement therapy in CAH patients by Otten et al.60 and Young et al.65 Both groups found the test to be useful for the assessment of control. In contrast to salivary 17-OHP concentrations, which are elevated above normal in CAH patients in good control, salivary AD results were within the reference range. For example, Otten et al. found a range of 40–50 pmol/L for salivary AD in 09:00 h samples from CAH children in good control, values which were well within the 09:00 h reference range of 20–250 pmol/L for normal prepubertal children.
Home-monitoring of CAH patients using salivary AD may serve as a useful adjunct to salivary 17-OHP measurements for the assessment of control.
Salivary AD and dihydrotestosterone concentrations in women with hyperandrogenism were studied by Baxendale et al.66 Salivary concentrations of both steroids were shown to reflect serum free concentrations in normal, hyperandrogenic and cyproterone acetate- or ethinyl oestradiol-treated patients.
Evidence for a more rapid conversion of AD to testosterone (T) in hirsute women was found by Swinkels et al.8 who demonstrated lower salivary AD:T ratios in these patients.
Further studies are needed to establish if salivary AD assays have a role in the investigation of hirsutism.

Salivary aldosterone

Assay methods for salivary aldosterone were first reported more than 20 y ago.67–69
Salivary aldosterone concentrations were found to be similar to those for serum free aldosterone, and represented approximately 30% of the corresponding serum total aldosterone concentration.68,70
Good correlation between salivary and serum free aldosterone has been reported (r = 0.84), with a weaker correlation between saliva and serum total aldosterone (r = 0.75).70 Salivary aldosterone was found to correlate with changes in serum total aldosterone in response to ACTH stimulation or dexamethasone suppression.67–69
Salivary/serum aldosterone ratios are unchanged during the first, second and third trimesters of pregnancy, and so salivary aldosterone had potential as a non-invasive assessment of aldosterone status during gestation.71
When sampled at frequent intervals, however, salivary aldosterone showed considerable fluctuations during the day, indicating the need for multiple samples to obtain reliable information.72
At present there is no information on the diagnostic value of salivary aldosterone measurements for the investigation of suspected primary hyperaldosteronism.

Salivary dehydroepiandrosterone

Salivary DHEA concentrations show good correlation with serum, and decreasing values with increasing age in adults have been well-documented.73,74
Despite a large number of publications in the literature on salivary DHEA measurement in the areas of DHEA supplementation,75 neuroendocrinology,76 and sports medicine,77 no routine diagnostic applications have been described. Salivary DHEA results in an individual show pulsatility, with large fluctuations during the day superimposed on a circadian rhythm similar to that for cortisol. Single saliva samples therefore have very little value, and repeated sampling is necessary to obtain consistent results.

Salivary oestradiol

Salivary E2 measurements have been used extensively in research studies on the menstrual cycle.78–80 Although they can be used to classify cycles, multiple samples are necessary to obtain reliable information. The main problem is that salivary E2 concentrations measured in individual women show a pulsatile pattern with cycles of 60–90 min; so sampling at multiple time points is necessary.81
Tivis et al.82 compared serum and salivary E2 values in 31 postmenopausal women on oral oestrogen therapy (‘Premarin’ tablets) with 12 patients who were not receiving oestrogen replacement. Their data showed that salivary E2 reflected serum E2 concentrations in women on oestrogen replacement (r = 0.81), but was very poorly correlated with serum E2 for women not receiving oestrogens (r = 0.32).
The need for multiple samples makes salivary E2 measurements impractical for routine assessment of oestrogen status.

Salivary unconjugated oestriol

Salivary E3 concentrations in the third trimester of pregnancy showed episodic fluctuations during the daytime, together with a circadian rhythm with concentrations increasing from 22:00 h, peaking at 04:00 h and returning to daytime concentrations at 06:00–07:00 h.83
Early publications demonstrated a correlation between salivary and serum unconjugated E3 concentrations, indicating their potential as an alternative to serum concentrations for the monitoring of feto-placental function.78,84,85
More recent research studies have assessed salivary E3 as an indicator of premature labour. A surge in salivary E3 concentration occurs 2–3 weeks before the onset of labour. Concentrations over 2.1 ng/mL (7.3 nmol/L) identified those pregnancies at risk of premature labour, while values less than this gave a confident prediction that delivery would not occur within 2–3 weeks.86,87
In spite of these research findings, salivary E3 assays do not have a routine application in the diagnostic laboratory.

Salivary progesterone

Multiple sequential samples for salivary progesterone have been used in a wide variety of applications as a non-invasive alternative to serum measurements.88,89 They have been particularly useful in research studies on girls during and after menarche, where there are ethical objections to blood sampling.90,91
When used as an index of ovulation, considerable discrepancy has been observed in classification between follicular and luteal phases,92 and relatively poor sensitivity (78%) and specificity (76.5%) for midluteal prediction of ovulation has been reported.93
In spite of the large number of publications on sequential measurements in the study of the menstrual cycle, salivary progesterone assays have not been adopted by diagnostic laboratories to check for ovulation or to assess luteal function. The main problem is that salivary P results show much greater variation over a 24-h period than that shown by serum concentrations. In a detailed study, Delfs et al.94 looked at 24-h salivary and serum P profiles and concluded that a single serum P correlated better with the 24-h mean serum P concentration than either a single saliva result or the mean of three saliva samples in the same individual.
One major manufacturer of salivary progesterone kits (IBL-Hamburg) comments in their literature on salivary P (and also on E2 and testosterone), that ‘single samples in most cases will give arbitrary results which are difficult to interpret’. They recommend taking five samples over a period of 2 h, and then analysing a pool made from these five samples, thus saving analytical costs.
It can be appreciated therefore, why routine diagnostic laboratories continue to measure serum P when faced with this rather cumbersome strategy for salivary P collection methods.
A single salivary P estimation is not as informative as a single serum P measurement, and therefore salivary P fails to meet the criteria for a routine diagnostic test.

Salivary testosterone

Salivary testosterone measurements have been applied to the investigation of male hypogonadism and of hirsutism or premature ovarian failure in women.
Salivary T in individuals can show rapid fluctuation even though smooth graphs of the changes in male salivary testosterone with age and with diurnal variation can be constructed from grouped data. This limits the value of a single determination, and therefore multiple samples are needed to obtain useful data.
Morley et al.95 established reference ranges for salivary testosterone in 127 men aged 20–89 y, and showed a 47% reduction over this age span. When salivary testosterone was compared with serum total, ‘bioavailable’ or calculated free testosterone, strong correlations were found, and in addition, salivary testosterone correlated with the results of two questionnaires assessing hypogonadal symptoms. However, the authors concluded that ‘salivary testosterone is not a better assay than other measures to diagnose hypogonadism’.
Although reasonable correlations between salivary and serum testosterone have been reported for combined data, when results for men and women are analysed separately, poorer correlations have been found, particularly for women.10,11 The use of salivary testosterone to assess hyperandrogenism in hirsute women is limited by a wide overlap between male and female reference ranges (Drs Teoh and Wallace, Glasgow Royal Infirmary, personal communication), and a single salivary testosterone result has been reported to give poorer discrimination than the conventional serum free androgen index.96
Salivary testosterone measurements may have some useful applications however.
In women with premature ovarian failure, salivary testosterone concentrations have been found to be consistently low or undetectable, while the serum free androgen index was within the reference range because of a reduction in both testosterone and sex hormone-binding globulin (SHBG) concentrations.97
A study of lumbar bone mass in healthy premenopausal women showed that high salivary testosterone concentrations were associated with higher lumbar bone mass, despite the fact that serum testosterone results were all normal.98
At present, the use of salivary testosterone measurements in the routine diagnostic laboratory cannot be recommended.

Conclusions and recommendations

There is good evidence to support the introduction of salivary cortisol as a screening test for Cushing's syndrome. Evening samples, or samples taken after low-dose dexamethasone testing have a sensitivity and specificity, which is as good as or better than conventional testing of serum cortisol following low-dose dexamethasone suppression or 24-h urine cortisol measurement. Salivary cortisol sampling is the method of choice for long-term assessment of patients with suspected cyclical Cushing's syndrome, and has potential for the investigation of possible hypoadrenalism with the Synacthen test.
Laboratories should consider the introduction of salivary cortisol for the routine investigation of patients for Cushing's syndrome.
Salivary 17-OHP and AD results are of value for the assessment of control in patients treated with hydrocortisone for CAH due to 21-hydroxylase deficiency. These tests should be considered by specialized endocrine laboratories to provide a home-monitoring service.
Salivary assays for oestradiol, progesterone, testosterone, DHEA and aldosterone are compromised by rapid fluctuations in concentrations, making collection of multiple samples necessary. They do not meet the criteria for routine diagnostic tests and their introduction into the laboratory repertoire cannot be justified at present.

ACKNOWLEDGEMENT

I am grateful to Mike Wallace and Brian Keevil for helpful comments and information during the writing of this review.

REFERENCES

1. Hofman LF. Human saliva as a diagnostic specimen. J Nutr 2001;135:1621S–25S
Crossref
Google Scholar
2. Kaufman E, Lamster IB. The diagnostic applications of saliva – a review. Crit Rev Oral Biol Med 2002;13:197–212
Crossref
PubMed
Google Scholar
3. Lewis JG. Steroid analysis in saliva: an overview. Clin Biochem Rev 2006;27:139–46
PubMed
Google Scholar
4. Vining RF, McGinley RA, Symons RG. Hormones in saliva: mode of entry and consequent implications for clinical interpretation. Clin Chem 1983;29:1752–6
Crossref
PubMed
ISI
Google Scholar
5. Shimojo M, Ricketts ML, Petrelli MD, et al. Immunodetection of 11 beta-hydroxysteroid dehydrogenase type 2 in human mineralocorticoid target tissues: evidence for nuclear location. Endocrinology 1997;138:1305–11
Crossref
PubMed
Google Scholar
6. Blom T, Ojanotko-Harri A, Laine M, Huhtaniemi I. Metabolism of progesterone and testosterone in human parotid and submandibular salivary glands in vitro. J Steroid Biochem Mol Biol 1993;44:69–76
Crossref
PubMed
Google Scholar
7. Rey F, Chiodori G, Gomez F, Febber JP. Interpretation of the discrepancy observed between plasma free and salivary testosterone levels in man. Steroids 1988;52:371–2
Crossref
PubMed
Google Scholar
8. Swinkels LM, van Hoof HJ, Rose HA, Smale AG, Benraad TJ. Low ratio of androstenedione to testosterone in plasma and saliva of hirsute women. Clin Chem 1992;38:12819–23
Crossref
Google Scholar
9. Djoseland O, du Bezche A, Hoglo S, Rennie PS. Steroid metabolism by normal and neoplastic parotid tissue. J Steroid Biochem 1982;16:397–402
Crossref
PubMed
Google Scholar
10. Broadbent JL. Salivary testosterone: is it an indicator of free testosterone concentration in plasma? NZJ Med Lab Sci 2002;56:85–9
Google Scholar
11. Granger DA, Shirtcliff EA, Booth A, Kivlighan KT, Schwartz EB. The ‘trouble’ with salivary testosterone. Psychoneuroendocrinology 2004;29:1229–40
Crossref
PubMed
Google Scholar
12. Vining RF, McGinley RA, Maksvytis JJ, Ho KY. Salivary cortisol: a better measure of adrenal cortisol function than serum cortisol. Ann Clin Biochem 1983;20:329–36
Crossref
PubMed
Google Scholar
13. Shannon IL, Prigmore JR, Chauncey HH. Modified Carlson-Crittenden device for the collection of parotid fluid. J Dent Res 1962;41:778–83
Crossref
PubMed
ISI
Google Scholar
14. Banerjee S, Levitz M, Rosenberg CR. On the stability of salivary progesterone under various conditions of storage. Steroids 1985;46:967–74
Crossref
PubMed
Google Scholar
15. Wade SE, Haegle AD. Differential measurement of cortisol and cortisone in human saliva by HPLC with UV detection. J Liquid Chromatogr 1991;14:1813–27
Crossref
Google Scholar
16. Shirtcliff EA, Granger DA, Schwartz E, Curran MJ. Use of salivary biomarkers in biobehavioral research: cotton based sample collection methods can interfere with salivary immunoassay results. Psychoneuroendocrinology 2001;26:165–73
Crossref
PubMed
ISI
Google Scholar
17. Groschl M, Rauh M. Influence of commercial collection devices for saliva on the reliability of salivary steroid analysis. Steroids 2006;71:1097–100
Crossref
PubMed
ISI
Google Scholar
18. Clements AD, Parker CR Jr, Dixon WE Jr, Salley B. Marshmallows used as saliva stimulant do not affect cortisol concentrations: finally a palatable alternative for toddler saliva collection. Dev Psychobiol 2007;49:702–7
Crossref
PubMed
Google Scholar
19. Vialard-Miguel J, Belaidi N, Lembeye L, Corcuff J-B. Lemon juice alters cortisol assays in saliva. Clin Endocrinol 2005;63:478–9
Crossref
PubMed
Google Scholar
20. Whembolua GL, Granger DA, Singer S, Kivlighan KT, Marguin JA. Bacteria in the oral mucosa and its effects on the measurement of cortisol, dehydroepiandrosterone and testosterone in saliva. Horm Behav 2006;49:478–83
Crossref
PubMed
Google Scholar
21. Groschl M, Wagner R, Rauh M, Dorr HG. Stability of salivary steroids: the influences of storage, food and dental care. Steroids 2001;66:737–41
Crossref
PubMed
Google Scholar
22. Garde AH, Hansen AM. Long term stability of salivary cortisol. Scand J Clin Lab Invest 2005;65:433–6
Crossref
PubMed
Google Scholar
23. Clements AD, Parker CR. The relationship between salivary cortisol concentrations in frozen versus mailed samples. Psychoneuroendocrinology 1998;23:613–16
Crossref
PubMed
ISI
Google Scholar
24. Aardal E, Holm AC. Cortisol in saliva – reference ranges and relation to cortisol in serum. Eur J Clin Chem Clin Biochem 1995;33:927–32
PubMed
Google Scholar
25. Kivlighan KT, Granger DA, Schwartz EB, Nelson V, Curran M, Shirtcliff EA. Quantifying blood leakage into the oral mucosa and its effects on the measurement of cortisol, dehydroepiandrosterone and testosterone in saliva. Horm Behav 2004;46:39–46
Crossref
PubMed
ISI
Google Scholar
26. Granger DA, Cicchetti D, Rogosch FA, Hibel LC, Jeisl M, Flores E. Blood contamination in children's saliva: prevalence, stability, and impact on the measurement of salivary cortisol, testosterone and dehydroepiandrosterone. Psychoneuroendocrinology 2007;32:724–33
Crossref
PubMed
Google Scholar
27. Dressendorfer RA, Kirschbaum C, Rohde W, Stahl F, Strasburger CJ. Synthesis of a cortisol-biotin conjugate and evaluation as a tracer in an immunoassay for salivary cortisol measurement. J Steroid Biochem Mol Biol 1992;43:683–92
Crossref
PubMed
Google Scholar
28. Wood PJ, Kilpatrick K, Barnard G. New direct salivary cortisol and cortisone assays using the ‘DELFIA’ system (Abstract). J Endocrinol 1997;155(Suppl. 2):71
Google Scholar
29. Porcu N. Salivary 17-Hydroxyprogesterone for the Monitoring of Steroid Replacement Therapy in Patients with Congenital Adrenal Hyperplasia. MSc dissertation. University of Surrey, Guildford, UK, 2006
Google Scholar
30. Baid SK, Sinaii N, Wade M, Rubino D, Nieman LK. Radioimmunoassay and tandem mass spectrometry measurement of bedtime salivary cortisol levels: a comparison of assays to establish hypercortisolism. J Clin Endocrinol Metab 2007;92:3102–7
Crossref
PubMed
ISI
Google Scholar
31. Dorn LD, Lucke JF, Loucks TL, Berga SL. Salivary cortisol reflects serum cortisol: analysis of circadian profiles. Ann Clin Biochem 2007;44:281–4
Crossref
PubMed
Google Scholar
32. Findling JW, Raff H, Aron DC. The low dose dexamethasone suppression test: a re-evaluation in patients with Cushing's syndrome. J Clin Endocrinol Metab 2004;89:1222–6
Crossref
PubMed
Google Scholar
33. Wood PJ, Barth JH, Friedman DB, Perry L, Sheridan B. Evidence for the low dose dexamethasone suppression test to screen for Cushing's syndrome – recommendations for a protocol for biochemistry laboratories. Ann Clin Biochem 1997;34:222–9
Crossref
PubMed
Google Scholar
34. Viardot A, Huber P, Puder JJ, Zulewski H, Keller V, Muller B. Reproducibility of night-time salivary cortisol and its use in the diagnosis of hypercortisolism compared with urinary free cortisol and overnight dexamethasone suppression test. J Clin Endocrinol Metab 2005;90:5730–6
Crossref
PubMed
Google Scholar
35. Gafni RI, Papanicolaou DA, Nieman LK. Night-time salivary cortisol measurement as a simple non-invasive outpatient screening test for Cushing's syndrome in children and adolescents. J Pediatr 2000;137:30–5
Crossref
PubMed
Google Scholar
36. Findling JW, Raff H. Cushing's syndrome: important issues in diagnosis and management. J Clin Endocrinol Metab 2006;91:3746–53
Crossref
PubMed
ISI
Google Scholar
37. Fegan PG, Sandeman DD, Krone N, et al. Cushing's syndrome in women with polycystic ovaries and hyperandrogenism. Nat Clin Pract Endocrinol Metab 2007;3:778–83
Crossref
PubMed
Google Scholar
38. Papanicolaou DA, Mullen N, Kyrou I, Nieman LK. Night-time salivary cortisol: a useful test for the diagnosis of Cushing's syndrome. J Clin Endocrinol Metab 2002;87:4515–21
Crossref
PubMed
Google Scholar
39. Putignano P, Toja P, Dubini A, Geraldi FP, Corsello SM, Cavagnini F. Midnight salivary cortisol versus urinary free and midnight serum cortisol as screening tests for Cushing's syndrome. J Clin Endocrinol Metab 2003;88:4153–7
Crossref
PubMed
Google Scholar
40. Meulenberg PMM, Hofman JA. Differences between concentrations of salivary cortisol and cortisone and of free cortisol and cortisone in plasma during pregnancy and parturition. Clin Chem 1990;36:70–5
Crossref
PubMed
Google Scholar
41. Kidambi S, Raff H, Findling JW. Limitations of nocturnal salivary cortisol and urine free cortisol in the diagnosis of mild Cushing's syndrome. Eur J Endocrinol 2007;157:725–31
Crossref
PubMed
Google Scholar
42. Atkinson AB, Kennedy AL, Carson DJ, Hadden DR, Weaver JA, Sheridan B. Five cases of cyclical Cushing's syndrome. Br Med J 1985;291:1453–7
Crossref
PubMed
Google Scholar
43. Meinardi JR, Wolffenbuttel BH, Dullaart RP. Cyclical Cushing's syndrome: a clinical challenge. Eur J Endocrinol 2007;157:245–54
Crossref
PubMed
Google Scholar
44. Laudat MH, Cerdas S, Fournier C, Guiban D, Guilhaume B, Luton JP. Salivary cortisol measurement: a practical approach to assess pituitary – adrenal function. J Clin Endocrinol Metab 1988;66:343–8
Crossref
PubMed
Google Scholar
45. Castro M, Elias LLK, Elias PCL, Moriera AC. A dose-response study of salivary cortisol after dexamethasone suppression test in Cushing's disease and its potential use in the differential diagnosis of Cushing's syndrome. Clin Endocrinol 2003;59:800–5
Crossref
PubMed
Google Scholar
46. Patel RS, Shaw SR, McIntyre HE, McGarry GW, Wallace AM. Morning salivary cortisol versus short Synacthen test as a test of adrenal suppression. Ann Clin Biochem 2004;41:408–10
Crossref
PubMed
Google Scholar
47. Suri D, Moran J, Hibbard JU, Kasza K, Weiss RE. Assessment of adrenal reserve in pregnancy: defining the normal response to adrenocorticotropin stimulation. J Clin Endocrinol Metab 2006;91:3866–72
Crossref
PubMed
Google Scholar
48. Arafah BM, Nishiyama FJ, Tlaygeh H, Hejal R. Measurement of salivary cortisol concentration in the assessment of adrenal function in critically ill subjects: a surrogate marker of the circulating free cortisol. J Clin Endocrinol Metab 2007;92:2965–71
Crossref
PubMed
Google Scholar
49. Contreras LN, Arregger AL, Persi GG, Gonzalez NS, Cardoso EM. A new less-invasive and more informative low-dose ACTH test: salivary steroids in response to intramuscular corticotrophin. Clin Endocrinol (Oxf) 2004;61:675–82
Crossref
PubMed
Google Scholar
50. Cardoso E, Persi G, Gonzalez N, et al. Assessment of adrenal function by measurement of salivary steroids in response to corticotrophin in patients infected with human immunodeficiency virus. Steroids 2007;72:328–34
Crossref
PubMed
Google Scholar
51. Arregger AL, Cardoso EM, Tumilasci O, Contreras LN. Diagnostic value of salivary cortisol in end stage renal disease. Steroids 2008;73:77–82
Crossref
PubMed
Google Scholar
52. Marcus-Perlman Y, Tordjman K, Greenman Y, et al. Low-dose ACTH (1µg) salivary test: a potential alternative to the classical blood test. Clin Endocrinol (Oxf) 2006;64:215–18
Crossref
PubMed
Google Scholar
53. Maguire AM, Ambler GR, Moore B, Waite K, McLean M, Cowell CT. The clinical utility of alternative, less invasive sampling techniques in the assessment of oral hydrocortisone therapy in children and adolescents with hypopituitarism. Eur J Endocrinol 2007;156:471–6
Crossref
PubMed
Google Scholar
54. Thomson AH, Devers MC, Wallace AM, et al. Variability in hydrocortisone plasma and saliva pharmacokinetics following intravenous and oral administration to patients with adrenal insufficiency. Clin Endocrinol (Oxf) 2007;66:789–96
Crossref
PubMed
Google Scholar
55. Lovas K, Thorsen TE, Husebye ES. Saliva cortisol measurement: simple and reliable assessment of the glucocorticoid replacement therapy in Addison's disease. J Endocrinol Invest 2006;29:727–31
Crossref
PubMed
Google Scholar
56. Lovas K, Husebye ES. Continuous subcutaneous hydrocortisone infusion in Addison's disease. Eur J Endocrinol 2007;157:109–12
Crossref
PubMed
ISI
Google Scholar
57. Zerah M, Pang S, New MI. Morning salivary 17-hydroxyprogesterone is a useful screening test for nonclassical 21-hydroxylase deficiency. J Clin Endocrinol Metab 1987;65:227–32
Crossref
PubMed
Google Scholar
58. Zerah M, Ueshiba H, Wood E, et al. Prevalence of nonclassical steroid 21-hydroxylase deficiency based on a morning saliva 17-hydroxyprogesterone screening test: a small sample study. J Clin Endocrinol Metab 1990;70:1662–7
Crossref
PubMed
Google Scholar
59. Ueshiba H, Zerah M, New MI. Enzyme-linked immunosorbent assay (ELISA) method for screening of non-classical steroid 21-hydroxylase deficiency. Horm Metab Res 1994;26:43–5
Crossref
PubMed
Google Scholar
60. Otten BJ, Wellan JJ, Rijken JCW, Stoelinga GBA, Benraad TJ. Salivary and plasma androstenedione and 17-hydroxyprogesterone levels in congenital adrenal hyperplasia. J Clin Endocrinol Metab 1983;57:1150–4
Crossref
PubMed
ISI
Google Scholar
61. Walker RF, Read GF, Hughes IA, Riad-Fahmy D. Radioimmunoassay of 17-hydroxyprogesterone in saliva, parotid fluid and plasma of congenital adrenal hyperplasia patients. Clin Chem 1979;25:542–5
Crossref
PubMed
Google Scholar
62. Young MC, Robinson JA, Read GF, Riad-Fahmy D, Hughes IA. 17-OH-Progesterone rhythm in congenital adrenal hyperplasia. Arch Dis Child 1988;63:617–23
Crossref
PubMed
Google Scholar
63. Dressendorfer RA, Strasburger CJ, Bidlingmaier F, et al. Development of a highly sensitive nonisotopic immunoassay for the determination of salivary 17-hydroxyprogesterone: reference ranges throughout childhood and adolescence. Paediatr Res 1998;44:650–5
Crossref
PubMed
Google Scholar
64. Groschl M, Rauh M, Dorr HG. Circadian rhythm of salivary cortisol, 17α-hydroxyprogesterone and progesterone in healthy children. Clin Chem 2003;49:1688–91
Crossref
PubMed
Google Scholar
65. Young MC, Walker RF, Riad-Fahmy D, Hughes IA. Androstenedione rhythms in saliva in congenital adrenal hyperplasia. Arch Dis Child 1988;63:624–8
Crossref
PubMed
Google Scholar
66. Baxendale PM, Jacobs HS, James VH. Plasma and salivary androstenedione and dihydrotestosterone in women with hyperandrogenism. Clin Endocrinol (Oxf) 1983;18:447–57
Crossref
PubMed
Google Scholar
67. McVie R, Levine LS, New MI. The biological significance of the aldosterone concentration in saliva. Pediatr Res 1979;13:755–9
Crossref
PubMed
Google Scholar
68. Atherden SM, Corrie JE, Jones DB, Al-Dujaili EA, Edwards CR. Development and application of a direct radioimmunoassay for aldosterone in saliva. Steroids 1985;46:845–55
Crossref
PubMed
Google Scholar
69. Few JD, Chaudry S, James VH. The direct determination of aldosterone in human saliva. J Steroid Biochem 1984;21:87–92
Crossref
PubMed
Google Scholar
70. Few JD, Wallis PJ, James VH. The relationship between salivary aldosterone and plasma free aldosterone concentrations. Clin Endocrinol (Oxf) 1986;24:119–26
Crossref
PubMed
Google Scholar
71. Few JD, Painlin DB, James VH. The relation between aldosterone concentration in plasma and saliva during pregnancy. Br J Obstet Gynaecol 1986;93:928–32
Crossref
PubMed
Google Scholar
72. Few JD, Unwin RJ, Carmichael DJ, James VH. Diurnal fluctuation in saliva aldosterone concentration. J Steroid Biochem 1987;26:265–71
Crossref
PubMed
Google Scholar
73. Granger DA, Schwartz EB, Booth A, Curran M, Zakaria D. Assessing dehydroepiandrosterone in saliva: a simple radioimmunoassay for use in studies of children, adolescents and adults. Psychoneuroendocrinolgy 1999;24:567–79
Crossref
PubMed
Google Scholar
74. Ahn RS, Lee YJ, Choi JY, Kwon MB, Chun SI. Salivary cortisol and DHEA levels in the Korean population: age-related differences, diurnal rhythm and correlations with serum levels. Yonsei Med J 2007;48:379–88
Crossref
PubMed
Google Scholar
75. Arlt W, Callies F, van Vlijmen JC, et al. Dehydroepiandrosterone replacement in women with adrenal insufficiency. N Engl J Med 1999;341:1013–20
Crossref
PubMed
Google Scholar
76. Wolf OT, Kirshbaum C. Actions of dehydroepiandrosterone and its sulphate in the central nervous system: effects on cognition and emotion in animals and humans. Brain Res Rev 1999;30:264–88
Crossref
PubMed
Google Scholar
77. Flynn MG, Pizza FX, Brolinson PG. Hormonal response to exercise training: influence of cross- training. Int J Sports Med 1997;18:191–6
Crossref
PubMed
Google Scholar
78. Evans JJ, Stewart CR, Merrick AY. Oestradiol in saliva during the menstrual cycle. Br J Obstet Gynaecol 1980;87:624–6
Crossref
PubMed
Google Scholar
79. Bao AM, Liu RY, van Someren EJ, Hofman MA, Cao YX, Zhou JN. Diurnal rhythm of free oestradiol during the menstrual cycle. Eur J Endocrinol 2003;148:227–32
Crossref
PubMed
Google Scholar
80. Gandara BK, Leresche L, Manci L. Patterns of salivary estradiol and progesterone across the menstrual cycle. Ann NY Acad Sci 2007;1098:446–50
Crossref
PubMed
Google Scholar
81. Chatterton RT Jr, Muteo ET, Hou N, et al. Characteristics of salivary profiles of oestradiol and progesterone in premenopausal women. J Endocrinol 2005;186:77–84
Crossref
PubMed
Google Scholar
82. Tivis LJ, Richardson MD, Peddi E, Arjmandi B. Saliva versus serum estradiol: implications for research studies using postmenopausal women. Prog Neuropsychopharmacol Biol Psychiatry 2005;29:727–32
Crossref
PubMed
Google Scholar
83. McGregor JA, Hastings C, Roberts T, Barrett J. Diurnal variation in saliva oestriol level during pregnancy: a pilot study. Am J Obstet Gynecol 1999;180:5223–5
Crossref
Google Scholar
84. Vining RF, McGinley R, Rice BV. Saliva estriol measurements: an alternative to the assay of serum unconjugated estriol in assessing fetoplacental function. J Clin Endocrinol Metab 1983;56:454–60
Crossref
PubMed
Google Scholar
85. Lechner W, Heim K, Zech J, Daxembichler C, Martin C. The relation between saliva oestriol levels in pregnancy and infant birth weight. Arch Gynecol Obstet 1987;241:9–12
Crossref
PubMed
Google Scholar
86. Heine RP, McGregor JA, Goodwin TM, et al. Serial salivary estriol to detect an increased risk of preterm birth. Obstet Gynecol 2000;96:490–7
PubMed
ISI
Google Scholar
87. McGregor JA, Hastings C, Dullien VV. A meta-analysis of salivary estriol (sE(3)) as a means to identify women at risk for preterm birth due to fetal- placental endocrine mechanisms. Prim Care Update Obstet Gynecol 1998;5:179–86
Crossref
PubMed
Google Scholar
88. Ellison PT. Measurements of salivary progesterone. Ann NY Acad Sci 1993;694:161–76
Crossref
PubMed
Google Scholar
89. Ellison PT. Salivary steroids and natural variation in human ovarian function. Ann NY Acad Sci 1994;709:287–98
Crossref
PubMed
Google Scholar
90. Read GF, Wilson DW, Hughes IA. The use of salivary progesterone in the assessment of ovarian function in post-menarchal girls. J Endocrinol 1984;102:265–8
Crossref
PubMed
Google Scholar
91. Groschl M, Rauh M, Schmidt P, Dorr HG. Relationship between salivary progesterone, 17-hydroxyprogesterone and cortisol levels throughout the normal menstrual cycle of healthy postmenarchal girls. Fertil Steril 2001;76:615–17
Crossref
PubMed
Google Scholar
92. Metcalf MG, Evans JJ, Mackenzie JA. Indices of ovulation: comparison of plasma and salivary levels of progesterone with urinary pregnanetriol. J Endocrinol 1984;100:75–80
Crossref
PubMed
Google Scholar
93. Ishikawa M, Sengoku K, Tamate K, Takaoka Y, Kane M, Fottrell PF. The clinical usefulness of salivary progesterone assessment for the evaluation of the corpus luteum function. Gynecol Obstet Invest 2002;53:32–7
Crossref
PubMed
Google Scholar
94. Delfs TM, Klein S, Fottrell P, Naether OG, Leidenberger FA, Zimmermann RC. 24-hour profiles of salivary progesterone. Fertil Steril 1994;62:960–6
Crossref
PubMed
Google Scholar
95. Morley JE, Perry HM III, Patrick P, Dollbaum CM, Kells JM. Validation of salivary testosterone as a screening test for male hypogonadism. Aging Male 2006;9:165–9
Crossref
PubMed
ISI
Google Scholar
96. Wang C, Wakelin K, White J, Wood PJ. Salivary androgens in hirsutism: are they of use in routine evaluation? Ann Clin Biochem 1986;23:590–5
Crossref
PubMed
ISI
Google Scholar
97. Mason A, Wallace AM, Macintyre H, et al. Undetectable salivary testosterone in young women with premature ovarian failure. Clin Endocrinol (Oxf) 2006;64:711–14
Crossref
PubMed
Google Scholar
98. Orozco P, Navarro MA, Nolla JM. Salivary testosterone is associated with higher lumbar bone mass in premenopausal healthy women with normal levels of serum testosterone. Eur J Epidemiol 2000;16:907–12
Crossref
PubMed
Google Scholar
99. Hubl W, Taubert H, Freymann E, et al. A simple solid phase enzyme immunoassay for aldosterone in plasma and saliva. Exp Clin Endocrinol 1983;82:188–93
Crossref
PubMed
Google Scholar
100. Riad-Fahmy D, Read GF, Walker RF, Griffiths K. Steroids in saliva for assessing endocrine function. Endocr Rev 1982;3:367–95
Crossref
PubMed
ISI
Google Scholar
101. Luthold WW, Marcondes JA, Wajchenberg BL. Salivary cortisol for the evaluation of Cushing's syndrome. Clin Chim Acta 1985;151:33–9
Crossref
PubMed
Google Scholar
102. Gallagher P, Leitch MM, Massey AE, McAllister-Williams RH, Young AH. Assessing cortisol and dehydroepiandrosterone (DHEA) in saliva: effects of collection method. J Psychopharmacol 2006;20:643–9
Crossref
PubMed
Google Scholar
103. Price DA, Astin MP, Chard CR, Addison GM. Assay of hydroxyprogesterone in saliva. Lancet 1979;1:368–9
Crossref
Google Scholar
104. Worthman CM, Stallings JF, Hofman LF. Sensitive salivary oestradiol assay for monitoring ovarian function. Clin Chem 1990;36:1769–73
Crossref
PubMed
Google Scholar
105. Wang DY, Fantl VE, Habibollahi F, et al. Salivary oestradiol and progesterone levels in premenopausal women with breast cancer. Eur J Cancer Clin Oncol 1986;22:487–92
Crossref
PubMed
Google Scholar
106. Lu Y, Bentley GR, Gann PH, Hodges KR, Chatterton RT. Salivary estradiol and progesterone levels in conception and non-conception cycles in women: evaluation of a new assay for salivary estradiol. Fertil Steril 1999;71:863–8
Crossref
PubMed
Google Scholar
107. Lachelin GC, McGarrigle HH. A comparison of saliva, plasma unconjugated and plasma total oestriol levels throughout normal pregnancy. Br J Obstet Gynaecol 1984;91:1203–9
Crossref
PubMed
Google Scholar
108. De Boever J, Kohen F, Vandekerckhova D. Direct solid phase chemiluminescence immunoassay for salivary progesterone. Clin Chem 1986;32:763–7
Crossref
PubMed
Google Scholar
109. Bolaji II. Sero-salivary progesterone correlation. Int J Gynaecol Obstet 1994;45:125–31
Crossref
PubMed
Google Scholar
110. Lu YC, Chatterton RT, Vogelsong KM, May LK. Direct radioimmunoassay of progesterone in saliva. J Immunoassay 1997;18:149–63
Crossref
PubMed
Google Scholar
111. Vitek J, L'Hommedieu DG, Gordon GG, Rappaport SC, Southern AL. Direct radioimmunoassay (RIA) of salivary testosterone: correlation with free and total serum testosterone. Life Sci 1985;37:711–16
Crossref
PubMed
Google Scholar
112. Barrou Z, Guiban D, Maroufi A, et al. Overnight dexamethasone suppression test: comparison of plasma and salivary cortisol measurement for the screening of Cushing's syndrome. Eur J Endocrinol 1996;134:93–6
Crossref
PubMed
Google Scholar
113. Raff H, Raff JL, Findling JW. Late-night salivary cortisol as a screening test for Cushing's syndrome. J Clin Endocrinol Metab 1998;83:2681–6
PubMed
Google Scholar
114. Castro M, Elias PC, Quidute ARP, Halah FPB, Moriera AC. Out-patient screening for Cushing's syndrome: the sensitivity of the combination of circadian rhythm and overnight dexamethasone suppression salivary cortisol tests. J Clin Endocrinol Metab 1999;84:878–82
PubMed
Google Scholar
115. Martinelli CE, Sader SL, Oliveira EB, Daneluzzi JC, Moreira AC. Salivary cortisol for screening for Cushing's syndrome in children. Clin Endocrinol 1999;51:67–71
Crossref
PubMed
Google Scholar
116. Yaneva M, Mosnier-Pudar H, Dugue M-A, Grabar S, Fulla Y, Bertagna X. Midnight salivary cortisol for the initial diagnosis of Cushing's syndrome of various causes. J Clin Endocrinol Metab 2004;89:3345–51
Crossref
PubMed
ISI
Google Scholar
117. Trilck M, Flitsch J, Ludecke DH, Jung R, Petersenn S. Salivary cortisol measurement – a reliable method for the diagnosis of Cushing's syndrome. Exp Clin Endocrinol Diabetes 2005;113:225–30
Crossref
PubMed
Google Scholar

Cite article

Cite article

Cite article

OR

Download to reference manager

If you have citation software installed, you can download article citation data to the citation manager of your choice

Share options

Share

Share this article

Share with email
EMAIL ARTICLE LINK
Share on social media

Share access to this article

Sharing links are not relevant where the article is open access and not available if you do not have a subscription.

For more information view the Sage Journals article sharing page.

Information, rights and permissions

Information

Published In

Volume 46, Issue 3
Pages: 183 - 196
Article first published online: January 28, 2009
Issue published: May 2009

Rights and permissions

© 2009 The Association for Clinical Biochemistry.
Request permissions for this article.
PubMed: 19176642

Authors

Affiliations

Department of Chemical Pathology, Southampton University Hospitals Trust, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK

Notes

Corresponding author: Peter Wood. Email: [email protected]
This article was prepared at the invitation of the Clinical Sciences Reviews Committee of the Association for Clinical Biochemistry.

Metrics and citations

Metrics

Journals metrics

This article was published in Annals of Clinical Biochemistry: International Journal of Laboratory Medicine.

VIEW ALL JOURNAL METRICS

Article usage*

Total views and downloads: 3048

*Article usage tracking started in December 2016

Altmetric

See the impact this article is making through the number of times it’s been read, and the Altmetric Score.
Learn more about the Altmetric Scores


Articles citing this one

Receive email alerts when this article is cited

Web of Science: 128 view articles Opens in new tab

Crossref: 0

  1. Investigation of Hypothalamic Pituitary Adrenal Axis and Oxytocinergic...
    Go to citation Crossref Google Scholar
  2. Diagnostic performance of an automated immunoassay for salivary cortis...
    Go to citation Crossref Google Scholar
  3. A promising approach for therapy control in congenital adrenal hyperpl...
    Go to citation Crossref Google Scholar
  4. A review of the analytical techniques for the detection of anabolic–an...
    Go to citation Crossref Google Scholar
  5. Tip-Enhanced Sub-Femtomolar Steroid Immunosensing via Micropyramidal F...
    Go to citation Crossref Google Scholar
  6. Blood and Salivary Cortisol Variations in Athletes in Relation to Card...
    Go to citation Crossref Google Scholar
  7. The Optimal Time-lag for Testosterone Challenge Research Based on Sali...
    Go to citation Crossref Google Scholar
  8. Relationship of Estradiol and Progesterone with Partnership and Parity...
    Go to citation Crossref Google Scholar
  9. Not within spitting distance: Salivary immunoassays of estradiol have ...
    Go to citation Crossref Google Scholar
  10. Role of Salivary Markers for Diagnosis of Systemic Diseases
    Go to citation Crossref Google Scholar
  11. Salivary 17-Hydroxyprogesterone Levels in Children with Congenital Adr...
    Go to citation Crossref Google Scholar
  12. The Involvement of the Hypothalamus-Pituitary-Adrenal Axis in the Deve...
    Go to citation Crossref Google Scholar
  13. Determination of Steroid Hormones in Human Saliva by High-Performance ...
    Go to citation Crossref Google Scholar
  14. Short-term serum and urinary changes in sex hormones of healthy pre-pu...
    Go to citation Crossref Google Scholar
  15. Steroidhormone aus Kapillarblut
    Go to citation Crossref Google Scholar
  16. Clinical and Technical Aspects in Free Cortisol Measurement
    Go to citation Crossref Google Scholar
  17. Methods for characterizing ovarian and adrenal hormone variability and...
    Go to citation Crossref Google Scholar
  18. No impact of developmental conditions on serum estradiol levels among ...
    Go to citation Crossref Google Scholar
  19. Measuring salivary cortisol in wild carnivores
    Go to citation Crossref Google Scholar
  20. Development of a Home-Based Stress Management Toolkit for Dementia Car...
    Go to citation Crossref Google Scholar
  21. Changes of Androstenone Concentrations in Saliva of Boars with Age
    Go to citation Crossref Google Scholar
  22. How to assess and interpret everyday life salivary cortisol measures: ...
    Go to citation Crossref Google Scholar
  23. Deep eutectic solvent extraction of cortisol and cortisone from human ...
    Go to citation Crossref Google Scholar
  24. Association between hair cortisol concentration and metabolic syndrome
    Go to citation Crossref Google Scholar
  25. Analytical Methods for the Determination of Neuroactive Steroids
    Go to citation Crossref Google Scholar
  26. Bioidentical hormones
    Go to citation Crossref Google Scholar
  27. Saliva diagnostics of sex hormones and subgingival microflora in child...
    Go to citation Crossref Google Scholar
  28. Association of salivary steroid hormones and their ratios with time-do...
    Go to citation Crossref Google Scholar
  29. Bestimmung von Sexualsteroiden in abgestoßener Haut der Gila-Krustenec...
    Go to citation Crossref Google Scholar
  30. Women With Generalized Anxiety Disorder Show Increased Repetitive Nega...
    Go to citation Crossref Google Scholar
  31. Current methods for stress marker detection in saliva
    Go to citation Crossref Google Scholar
  32. Stimulated Salivary Cortisol as a Noninvasive Diagnostic Tool for Adre...
    Go to citation Crossref Google Scholar
  33. Screening and identification of salivary biomarkers for assessing the ...
    Go to citation Crossref Google Scholar
  34. Determination of the steroid profile in alternative matrices by liquid...
    Go to citation Crossref Google Scholar
  35. Effect of 8-week n-3 fatty-acid supplementation on oxidative stress an...
    Go to citation Crossref Google Scholar
  36. Study of temporal variability of salivary cortisol and cortisone by LC...
    Go to citation Crossref Google Scholar
  37. A sensitive chemiluminescence based immunoassay for the detection of c...
    Go to citation Crossref Google Scholar
  38. Methodological Recommendations for Menstrual Cycle Research in Sports ...
    Go to citation Crossref Google Scholar
  39. Long-term follow-up of children with classic congenital adrenal hyperp...
    Go to citation Crossref Google Scholar
  40. Determination, intercorrelation and intraindividual stability of five ...
    Go to citation Crossref Google Scholar
  41. Blood contamination in salivary diagnostics: current methods and their...
    Go to citation Crossref Google Scholar
  42. Laboratory tests commonly used in complementary and alternative medici...
    Go to citation Crossref Google ScholarPub Med
  43. Evaluating the four most important salivary sex steroids during male p...
    Go to citation Crossref Google Scholar
  44. A Randomized, Double-Blind, Placebo-Controlled, Crossover Study Examin...
    Go to citation Crossref Google ScholarPub Med
  45. Urinary excretion of sex steroid hormone metabolites after consumption...
    Go to citation Crossref Google Scholar
  46. Use of Saliva in Alternative to Serum Sampling to Monitor Biomarkers M...
    Go to citation Crossref Google Scholar
  47. Quantification of 10 steroid hormones in human saliva from Chinese adu...
    Go to citation Crossref Google ScholarPub Med
  48. Relationship between testosterone in serum, saliva and urine during tr...
    Go to citation Crossref Google Scholar
  49. Salivary alpha amylase not chromogranin A reflects sympathetic activit...
    Go to citation Crossref Google Scholar
  50. Neural mechanisms of individual differences in temporal discounting of...
    Go to citation Crossref Google Scholar
  51. Simultaneous assay of cortisol and dexamethasone improved diagnostic a...
    Go to citation Crossref Google Scholar
  52. Sinn und Unsinn von Speicheltests auf Hormone
    Go to citation Crossref Google Scholar
  53. High salivary testosterone‐to‐androstenedione ratio and adverse metabo...
    Go to citation Crossref Google Scholar
  54. Placental hormone profiles as predictors of preterm birth in twin preg...
    Go to citation Crossref Google Scholar
  55. Salivary Cortisol and Cortisone After Low-Dose Corticotropin Stimulati...
    Go to citation Crossref Google Scholar
  56. Parallel diurnal fluctuation of testosterone, androstenedione, dehydro...
    Go to citation Crossref Google Scholar
  57. Potential detection of low‐dose transdermal testosterone administratio...
    Go to citation Crossref Google Scholar
  58. Validation of an LC–MS/MS salivary assay for glucocorticoid status ass...
    Go to citation Crossref Google Scholar
  59. Naturally Occurring Changes in Estradiol Concentrations in the Menopau...
    Go to citation Crossref Google ScholarPub Med
  60. Analytical Evaluation of Free Testosterone and Cortisol Immunoassays i...
    Go to citation Crossref Google Scholar
  61. Salivary cortisol and explicit memory in postmenopausal women using ho...
    Go to citation Crossref Google Scholar
  62. Laboratory Techniques for Recognition of Endocrine Disorders
    Go to citation Crossref Google Scholar
  63. Variability in laboratory parameters used for management of Cushing’s ...
    Go to citation Crossref Google Scholar
  64. Adrenal, Reproductive, and Thyroid Hormone Testing for Depression
    Go to citation Crossref Google Scholar
  65. Salivary Hormones Response to Preparation and Pre-competitive Training...
    Go to citation Crossref Google Scholar
  66. Salivary cortisol and cortisone responses to tetracosactrin (synacthen...
    Go to citation Crossref Google ScholarPub Med
  67. The Effects of Sex Hormonal Fluctuations during Menstrual Cycle on Cor...
    Go to citation Crossref Google Scholar
  68. Re: Emotions, immunity and sport: Winner and loser athlete’s profile o...
    Go to citation Crossref Google Scholar
  69. Variations in resting frontal alpha asymmetry between high‐ and low‐ne...
    Go to citation Crossref Google Scholar
  70. The effect of storage conditions on salivary cortisol concentrations u...
    Go to citation Crossref Google Scholar
  71. Salivary morning androstenedione and 17α-OH progesterone levels in chi...
    Go to citation Crossref Google Scholar
  72. The Utility and Dynamics of Salivary Sex Hormone Measurements in the N...
    Go to citation Crossref Google Scholar
  73. A Comparison of Capillary, Venous, and Salivary Cortisol Sampling afte...
    Go to citation Crossref Google Scholar
  74. Saliva stimulation with glycerine and citric acid does not affect sali...
    Go to citation Crossref Google Scholar
  75. Anwendungsgebiete und Analytik
    Go to citation Crossref Google Scholar
  76. The Effect of Acute Exercise and Psychosocial Stress on Fine Motor Ski...
    Go to citation Crossref Google Scholar
  77. The Potential Role of Oral Fluid in Antidoping Testing
    Go to citation Crossref Google Scholar
  78. The effects of saliva collection, handling and storage on salivary tes...
    Go to citation Crossref Google Scholar
  79. Measurement of steroid hormones in saliva: Effects of sample storage c...
    Go to citation Crossref Google Scholar
  80. Seasonal pattern of salivary cortisol secretion in the greater one-hor...
    Go to citation Crossref Google Scholar
  81. Novel liquid chromatography tandem mass spectrometry (LC-MS/MS) method...
    Go to citation Crossref Google Scholar
  82. Principles and pitfalls of free hormone measurements
    Go to citation Crossref Google Scholar
  83. Influence of acute and chronic physical activity on cognitive performa...
    Go to citation Crossref Google Scholar
  84. Reproductive hormone concentrations in pregnancy and neonates: a syste...
    Go to citation Crossref Google Scholar
  85. Therapy of adrenal insufficiency: an update
    Go to citation Crossref Google Scholar
  86. Disorders of male fertility
    Go to citation Crossref Google Scholar
  87. Androgen deficiency in the male
    Go to citation Crossref Google Scholar
  88. Tandem Mass Spectrometry in Hormone Measurement
    Go to citation Crossref Google Scholar
  89. Hirsutism and Virilization in the Female
    Go to citation Crossref Google Scholar
  90. Steroid concentrations in antepartum and postpartum saliva: normative ...
    Go to citation Crossref Google Scholar
  91. Effects of the UK Biobank collection protocol on potential biomarkers ...
    Go to citation Crossref Google Scholar
  92. Changes in steroid hormones during an international powerlifting compe...
    Go to citation Crossref Google Scholar
  93. Circadian Rhythm of Salivary Cortisol in Asian Elephants ( ...
    Go to citation Crossref Google Scholar
  94. Salivary concentration of progesterone and cortisol significantly diff...
    Go to citation Crossref Google Scholar
  95. Adrenal function in cirrhosis: The pendulum swings
    Go to citation Crossref Google Scholar
  96. Stress-Coping and Cortisol Analysis in Patients with Non-Syndromic Cle...
    Go to citation Crossref Google Scholar
  97. Potential And Limitations of Alternative Specimens in Doping Control
    Go to citation Crossref Google Scholar
  98. Adrenocortical dysfunction in liver disease: A systematic review
    Go to citation Crossref Google Scholar
  99. Seasonal rhythms of salivary cortisol secretion in captive Asian eleph...
    Go to citation Crossref Google Scholar
  100. Salivary cortisol as a diagnostic tool for Cushing's syndrome and adre...
    Go to citation Crossref Google Scholar
  101. Determination of salivary testosterone and androstendione by liquid ch...
    Go to citation Crossref Google Scholar
  102. Salivary testosterone: Associations with depression, anxiety disorders...
    Go to citation Crossref Google Scholar
  103. Reproductive Endocrinology and Related Disorders
    Go to citation Crossref Google Scholar
  104. Challenges and Benefits of Endogenous Steroid Analysis by LC–MS/MS
    Go to citation Crossref Google Scholar
  105. Challenges for the endocrine laboratory in critical illness
    Go to citation Crossref Google Scholar
  106. Analytical error and interference in immunoassay: minimizing risk
    Go to citation Crossref Google ScholarPub Med
  107. Measuring stress in wildlife: techniques for quantifying glucocorticoi...
    Go to citation Crossref Google Scholar
  108. Are salivary gonadal steroid concentrations influenced by acute psycho...
    Go to citation Crossref Google Scholar
  109. An update: salivary hormones and physical exercise
    Go to citation Crossref Google Scholar
  110. Salivary testosterone for the diagnosis of androgen deficiency in end-...
    Go to citation Crossref Google Scholar
  111. Androgen Deficiency
    Go to citation Crossref Google Scholar
  112. Cerebrospinal, Synovial, Serous Body Fluids, and Alternative Specimens
    Go to citation Crossref Google Scholar
  113. Menstrual cycle modulation of medial temporal activity evoked by negat...
    Go to citation Crossref Google Scholar
  114. Characterising adrenal function using directly measured plasma free co...
    Go to citation Crossref Google Scholar
  115. Hormonothérapie bio-identique: synthèse pratique à l'intention des pha...
    Go to citation Crossref Google Scholar
  116. Ultradian rhythmicity and induced changes in salivary testosterone
    Go to citation Crossref Google Scholar
  117. Steroid measurement with LC–MS/MS. Application examples in pediatrics
    Go to citation Crossref Google Scholar
  118. Current World Literature
    Go to citation Crossref Google Scholar
  119. Clinical accuracy of midnight salivary cortisol measured by automated ...
    Go to citation Crossref Google ScholarPub Med
  120. Salivary testosterone, cortisol, and progesterone: Two-week stability,...
    Go to citation Crossref Google Scholar
  121. Serum total cortisol and free cortisol index give different informatio...
    Go to citation Crossref Google ScholarPub Med
  122. Utility of Salivary Cortisol Measurements in Cushing’s Syndrome and Ad...
    Go to citation Crossref Google Scholar
  123. Salivary steroids
    Go to citation Crossref Google ScholarPub Med
  124. Salivary steroid assays: still awaiting a killer application
    Go to citation Crossref Google ScholarPub Med
  125. The ecology and evolutionary endocrinology of reproduction in the huma...
    Go to citation Crossref Google Scholar

Figures and tables

Figures & Media

Tables

View Options

View options

PDF/ePub

View PDF/ePub

Get access

Access options

If you have access to journal content via a personal subscription, university, library, employer or society, select from the options below:

ACB members can access this journal content using society membership credentials.

MEMBERSHIP LOGIN

ACB members can access this journal content using society membership credentials.

MEMBERSHIP LOGIN

Alternatively, view purchase options below:

Purchase 24 hour online access to view and download content.

Subscribe to this journal

Access journal content via a DeepDyve subscription or find out more about this option.

Start 2 week free trial
Need help?

Also from Sage