BlueCross BlueShield of Tennessee Medical Policy Manual

Salivary Testing for Steroid Hormone Levels


Salivary testing is proposed as a non-invasive method for measuring steroid hormones which are typically measured in blood and urine samples.  These hormones include estrogens, progesterone, testosterone, cortisol, melatonin and dehydroepiandrosterone (DHEA).  

Several studies have shown that salivary testing is an effective tool in screening for Cushing syndrome.  The late-night salivary cortisol test is used in the home setting by individuals with a regular sleep pattern.  Saliva specimen is collected at bedtime and sent to a laboratory.  The test detects elevated nighttime cortisol levels which appear to be the earliest and most sensitive markers for Cushing syndrome.  If the screening test results are positive, confirmatory tests are then performed.

Salivary hormone testing is also proposed for use by individuals receiving bioidentical hormone therapy, compounded preparations for the treatment of menopause.  Proponents of the therapy recommend salivary testing as a means of providing individualized therapy; however, since hormones fluctuate based on diet, hydration and other variables, these conditions are difficult to standardize.

Dehydroepiandrosterone (DHEA) and its sulfated analog (DHEAS) are also steroid hormones, principally made in the adrenal cortex. DHEAS is converted into various estrogenic and androgenic compounds. Evidence supporting DHEA and/or DHEAS salivary testing as an effective biomarker is lacking.




The evidence to support salivary testing for reasons other than to screen for Cushing syndrome is of very low quality and conclusions cannot be drawn regarding the accuracy of saliva testing.


American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons. (2009, July/August). Medical guidelines for the management of adrenal incidentalomas. Retrieved January 28, 2015 from  

American Association of Clinical Endocrinologists. (2011, November/December). Medical guidelines for clinical practice for the diagnosis and treatment of menopause. Retrieved February 3, 2015 from

Davis, G., Gallien, G., Moody, K., LeBlanc, N., Smoak, P., & Bellar, D. (2015). Cognitive function and salivary DHEA levels in physically active elderly African American women. International Journal of Endocrinology, 2015:219046. (Level 4 evidence)

Duskova, M., Simunkova, K., Vitku, J., Sosvorova, L., Jandikova, H., Pospisilova, J., et. al. (2016) A Comparison of salivary steroid levels during diagnostic tests for adrenal insufficiency. Prague Medical Report, Vol. 117, No. 1, p. 18-33. (Level 4 evidence)

Graham, U., Hunter, S., McDonnell, M., Mullan, K., & Atkinson, A. (2013). A comparison of the use of urinary cortisol to creatinine ratios and nocturnal salivary cortisol in the evaluation of cyclicity in patients with Cushing’s syndrome. Journal of Clinical Endocrinology and Metabolism, 98 (1), E72-E76. Abstract retrieved June 7, 2016 from PubMed database.

Keevil, B., Macdonald, P., Macdowall, W., Lee, D., Wu, F., & the NATSAL Team. (2013). Salivary testosterone measurement by liquid chromatography tandem mass spectrometry in adult males and females. Annals of Clinical Biochemistry, 51 (3), 368-378. (Level 4 evidence)

North American Menopause Society. (2017). The 2017 hormone therapy position statement of The North American Menopause Society. Retrieved June 28, 2017 from

The American College of Obstetricians and Gynecologists, Committee on Gynecologic Practice and the American Society for Reproductive Medicine Practice Committee. (2012, August). Committee Opinion No. 532: Compounded bioidentical menopausal hormone therapy. Retrieved June 7, 2016 from

U.S. Food and Drug Administration. (2015, November). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K150528. Retrieved June 7, 2016 from

Winifred S. Hayes, Inc. Medical Technology Directory. (2013, July; last update search June 2017). Salivary hormone testing for menopausal women. Retrieved June 28, 2017 (92 articles and/or guidelines reviewed)




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