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

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 College of Obstetricians and Gynecologists, Committee on Gynecologic Practice and the American Society for Reproductive Medicine Practice Committee. (2012, August; reaffirmed 2018). Committee Opinion No. 532: Compounded bioidentical menopausal hormone therapy. Retrieved April 29, 2019 from

Mezzullo, M., Fazzini, A., Gambineri, A., Di Dalmazi, G., Mazza, R., Pelusi, C, et al. (2017). Parallel diurnal fluctuation of testosterone, androstenedione, dehydroepiandrosterone and 17OHprogesterone as assessed in serum and saliva: validation of a novel liquid chromatography-tandem mass spectometry method for salivary steroid profiling. Clinical Chemistry and Laboratory Medicine, 55 (9), 1315-1323. Abstract retrieved April 30, 2019.  

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




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