Trouble With The Curve:  It’s Not Just a Movie

Trouble With The Curve:  It’s Not Just a Movie

A practitioner’s approach to the cortisol curve

 By: Benita Phillips, D.O.


How many times have you looked at a patient’s cortisol curve and said to yourself:

“That just doesn’t make sense!” 

And you think:

“This person should feel fine…”

Or the contrary:

“How does this patient even get out of bed?”

And then you see it, the dreaded up and down zigzag pattern of cortisol levels all day long, fluctuating faster than gas prices on a holiday weekend. And all the while you’re wondering why their symptoms don’t match the curve – they’re supposed to!

What We Knew

We were taught to treat adrenal dysfunction based on 4 or 5 cortisol levels measured throughout the day, called a diurnal curve.

We were taught to use certain supplements to treat high cortisol levels and certain supplements to treat low cortisol levels.

We were taught to use certain supplements for patients who had a cortisol curve that looked like the rickrack my grandmother sewed onto my homemade clothes as a child.

We learned the symptoms of adrenal dysfunction.

We learned that high cortisol causes things like anxiousness and cravings for sugar and carbs, and we learned that low cortisol causes symptoms like fatigue and salt cravings.

But what can be confusing and frustrating are those cortisol levels that do not explain the symptoms – or worse yet – the patient whose symptoms do not resolve with the supplement designated for their cortisol levels.

What We Know, Now

Enter Physicians Lab and their 24-hour urinary hormone testing.  The report includes not only the standard 5-point cortisol levels and curve but also includes total cortisol metabolites; the cortisol:metabolite ratio and a 5-point cortisone curve (an adrenal game changer!).

Now we can see not only the cortisol curve, but we can also see how each patient metabolizes his or her cortisol.  This is especially important for those patients whose symptoms do not match their cortisol levels.

In addition to studying the individual cortisol values and the diurnal curve, it is very imperative to look at the cortisol:metabolite ratio.  As long as this ratio is in the mid-target range (best being 1), then you know that the reported cortisol levels can be interpreted as is.  Meaning they are true and accurate levels.

However, if the cortisol:metabolite ratio is elevated, then the patient is not metabolizing cortisol well.  He or she has a decreased cortisol metabolism.  This may indicate that the actual cortisol levels could be misinterpreted as the result of increased adrenal production.  The levels may be falsely high.

If the cortisol:metabolite ratio is low, then the patient has increased metabolism of cortisol.  This can cause cortisol levels to be misinterpreted as the product of decreased adrenal production.  The levels may be a false low.

Careful Considerations

At this point, we need to remember that abnormal cortisol metabolism changes only the height of the curve.  It is important to note that an abnormal cortisol metabolism does not change the shape of the curve. The shape of the diurnal curve is still the best way to assess adrenal health and function throughout the day.  Let the shape of the curve guide you in your decision process for supplement use.

We also need to remember that decreased cortisol metabolism is often the first indicator of hypothyroidism.  And, an increased cortisol metabolism (false low curve), indicates that the patient is at high risk for obesity, metabolic syndrome, insulin resistance, and type 2 diabetes.

Supplemental Solutions

Lifestyle changes, as well as carefully chosen supplements, are essential for adrenal health. The following lifestyle changes are imperative for the patient with adrenal dysfunction of any kind, no matter what the trouble with the curve:

  • – Healthy diet with an emphasis on vegetables and some well-chosen fruits. Think berries!
  • – Daily exercise
  • – Stress reduction techniques
  • – Sufficient, quality sleep
  • – Daily supplements – fish oil, multivitamin, vitamin D, probiotic

With so many quality adrenal supplements available at our fingertips to help treat different adrenal issues, below are three of my favorites:

  • – Pure Calm – for truly elevated levels
  • – Pure Lift – for truly low levels
  • – Adapto-Pure – for that zigzag pattern


The good thing is that if you have questions about your patient’s results, the friendly folks at Physicians Lab are ready and willing to help interpret results, so you have a clear understanding of what is going on. They can be reached Monday-Friday at (877)316-8686, option 2.



Benita Phillips, DO received her doctorate of Osteopathic Medicine at Oklahoma State University’s College of Osteopathic Medicine in 2000. She went on to complete her residency in Family Medicine at the University of Oklahoma College of Medicine in Tulsa, where she earned the honor of Chief Resident in back to back years (2002-2003). In 2003, Dr. Phillips became Board Certified by the American Board of Family Practice and was awarded both The Paul E. Tietze Memorial Award for Commitment to Patient Care and the Keeping Up With the Times Award for Research Excellence. She later was presented with the Physician’s Recognition Award by the American Medical Association in 2007. Dr. Benita Phillips is an active member of the fellowship in Regenerative Medicine and the American Academy of Anti-Aging and Regenerative Medicine (A4M). She is also an active member of the American Medical Association and the American Academy of Family Physicians.

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