What a Hormone Panel Should Include for Men

A hypothetical 46 year old man comes in with low energy, a harder time holding muscle and less interest in sex. His doctor checked a total testosterone, it came back at 410, and he was told it was normal. It may be. But a single total testosterone is one number standing in for a system with several moving parts, and it misses the picture more often than people expect.

The five numbers

Total testosterone is the amount in the blood, bound and unbound together. It is the starting point, not the answer. Most of it is attached to proteins, mainly one called SHBG, and testosterone attached to SHBG is not available to tissue. Only the free fraction, roughly 2 percent of the total, plus the share held loosely on albumin, is readily available to muscle, brain and bone.

Free testosterone is that active fraction, measured directly or calculated from total testosterone, SHBG and albumin. Two men with the same total of 410 can have very different free levels.

SHBG explains why. It rises with age, with low insulin levels, with thyroid excess and with some medications, and it falls with body fat and insulin resistance. A lean 50 year old with high SHBG can have a normal total and a low free level, and feel every bit of it. A heavier man with low SHBG can have a low total and a free level that is actually fine. Without SHBG on the sheet, a total anywhere near the edge of the range cannot be read correctly.

Estradiol matters because fat tissue converts testosterone into estrogen through an enzyme called aromatase. In men with more body fat, that conversion pulls testosterone down and pushes estradiol up, which can bring on breast tenderness, water retention and mood changes. On treatment it needs watching for the same reason. It has to be measured with the sensitive assay, because the standard estradiol test built for women is not accurate at male levels.

LH, luteinizing hormone, is the signal from the pituitary that tells the testes to make testosterone. It tells us where a low number is coming from. High LH with low testosterone means the testes are not responding. Low or normal LH with low testosterone means the signal itself is weak, and that points upstream to sleep, weight, stress, illness, medications such as opiates, or less often a problem in the pituitary itself. Those are two different problems with two different plans.

How we draw it

Testosterone peaks in the morning and falls through the day, so the draw happens before about 10 a.m., fasting, and a low result gets confirmed on a second morning before anyone is treated. For men on treatment, we repeat the full panel at least yearly, along with a blood count, since testosterone can raise hematocrit, and a PSA.

The goal is to optimize hormones based on the whole picture rather than chase a single number into a reference range.

That's why we check all five.

This article is educational and is not medical advice.

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