Male Sex Hormone Monitoring and Testing#

Free testosterone is the small fraction (about 1-3% of total testosterone) that is not bound to any protein. It is the part that crosses cell membranes and exerts hormonal effects. Calculated free testosterone uses total testosterone and SHBG to estimate the free amount and is generally preferred over direct free-testosterone immunoassays, which are unreliable.

SHBG levels change with body weight, age, thyroid status, liver function, and medications. High SHBG (more carrier protein) reduces the free fraction even if total testosterone looks normal; low SHBG raises the free fraction. Without knowing SHBG, a "normal" total testosterone can hide either a real deficiency or a normal-functioning system.

Testosterone gradually declines with age, roughly 1-2% per year after about age 30-40. A 30-year-old with a total of 10 nmol/L is typically symptomatic; a 75-year-old with the same number may be asymptomatic. Age-adjusted ranges are not standardized in Canada, so most labs report the broad adult-male range. Your clinician interprets the number alongside your age and symptoms.

This is common. The Endocrine Society and the Canadian Society of Endocrinology and Metabolism both recommend testing when symptoms are present. A normal result rules testosterone out as the cause and points the workup toward other contributors. A low result may or may not be the explanation; it has to be interpreted in context.

No. Routine screening of asymptomatic adult men is not recommended by any major guideline. Testing without symptoms tends to produce borderline results that lead to unnecessary further testing without changing outcomes.

Higher baseline risk includes: type 2 diabetes, obesity, chronic opioid use, long-term oral steroid use, prior chemotherapy or pelvic radiation, prior testicular injury or torsion, undescended testis history, HIV infection, chronic kidney or liver disease, and known pituitary disease. In these settings a lower threshold for testing is reasonable.

The result is still informative, but a low value drawn late morning or afternoon should always be repeated in the early morning before drawing conclusions. A normal value drawn late morning is meaningful (it implies an even higher early-morning value).

Testosterone varies enough day-to-day that 20-30% of men with a single low value have a normal value on a repeat draw. Acting on a single low value risks treating people who do not actually have low testosterone. Two separate low morning values plus symptoms is the diagnostic standard.

Salivary testosterone has poor correlation with blood testosterone and is not used in Canadian clinical practice. Blood is the standard.

When testing testosterone in someone with possible low T, a useful workup also includes:

• CBC (hemoglobin/hematocrit baseline)
• HbA1c and fasting glucose (diabetes screen)
• Lipid panel
• Ferritin (iron stores)
• Creatinine and eGFR (kidney function)
• AST/ALT (liver function)
• Vitamin D
• PSA (prostate-specific antigen) - baseline before any potential treatment in age 40+
• Sleep history or sleep-study questionnaire if sleep apnea is suspected

This workup looks for the contributors and rules-outs that change management.

The most useful next steps:

1. Confirm with a repeat early-morning, fasting draw
2. Calculate free testosterone using SHBG
3. Check LH, FSH, prolactin to see where the problem is
4. Look for reversible contributors (see next section)
5. Address contributors first; recheck before deciding on treatment

Many people in the grey zone improve significantly when reversible causes are addressed.

Total testosterone of 10-13 nmol/L is sometimes called "low normal." It is in the reference range but at the lower end. Whether this matters depends on symptoms, the trend over time, the free testosterone, and reversible contributors. By itself, "low normal" is generally not a reason to start treatment.

A value far above the reference range in someone not taking exogenous testosterone is unusual and prompts further evaluation - testosterone-secreting tumours are rare but exist. In someone on TRT, a high value usually indicates the dose is too high and should be reduced.

A meaningful amount. Studies in men with obesity show roughly a 3-5 nmol/L total testosterone rise with a 10% weight loss. For a man whose total testosterone is 9 nmol/L at a body weight that is 20% above his target, weight loss alone can take him out of the deficient range. This is the most under-used "treatment" for low testosterone.

Recovery is variable. Many people see partial recovery in 3-6 months and more complete recovery by 12-24 months. Recovery is not guaranteed; long, high-dose use can produce persistent suppression. Sperm production typically follows testosterone with a lag.

Opioid-induced testosterone suppression is well documented. If you cannot reduce or stop opioids, this is a setting where TRT is sometimes considered after a careful conversation with your pain provider and the prescriber.

It restores blood testosterone to the normal adult-male range when natural production is insufficient. Reported clinical benefits in appropriately selected patients include: improved sexual function and libido, improved mood and energy, increased muscle mass and strength, improved bone density, and reduced fat mass. Effects vary by individual and by what symptoms were present at baseline. TRT does not "rejuvenate" or reverse aging.

In most cases of genuine hypogonadism (especially primary hypogonadism), yes. In secondary hypogonadism with a reversible cause (recovered weight loss, treated sleep apnea, stopped anabolic steroid use), TRT can sometimes be tapered after the underlying issue is addressed. A trial period of treatment followed by a planned reassessment is sometimes used.

Recognized risks include: erythrocytosis (high hematocrit / thickened blood, raising clot risk), worsening of sleep apnea, possible breast tenderness or gynecomastia, acne or oily skin, fluid retention, testicular shrinkage, and suppression of fertility (see Fertility section). Cardiovascular safety has been studied at length; the TRAVERSE trial (2023) found TRT did not raise the risk of major adverse cardiovascular events in men at elevated cardiovascular risk when used appropriately. Long-term prostate cancer risk has not been shown to be elevated in well-designed studies.

Erythrocytosis means too many red blood cells (high hemoglobin and hematocrit). Testosterone stimulates red blood cell production; in some people this overshoots. Thickened blood raises the risk of blood clots, stroke, and heart attack. The threshold for action is usually hematocrit above about 52-54%. Options when this happens: lower the dose, change the route, donate blood periodically, or pause treatment. Monitoring CBC at 3 months and then periodically catches this before it becomes dangerous.

Current evidence does not support a causal link between TRT and prostate cancer. People with active prostate cancer should not be on TRT. PSA monitoring is part of standard monitoring on TRT in age-appropriate patients (typically age 40+). A significant rise in PSA prompts a urology referral.

The dose is reduced or the frequency adjusted. Levels persistently above the upper reference range are not the goal of treatment and raise the risk of erythrocytosis, mood changes, and other side effects without adding benefit.

Most men recover sperm production within 6-18 months after stopping TRT, though full recovery to pre-treatment levels can take longer. Studies suggest about 90% of men return to detectable sperm counts within 24 months. Recovery is less predictable after long-term use, high-dose use, or use of anabolic-steroid stacks alongside TRT.

Yes, and we strongly recommend considering this if biological fertility is even a possibility for you in the future. Sperm banking is done through a fertility clinic. TeleTest can discuss the decision but does not perform banking itself.

The usual approach is to pause TRT and work with a fertility specialist or urologist on a recovery plan. Some patients are managed with TRT alternatives that preserve fertility; these are specialist decisions. Plan ahead - recovery is not immediate.

Yes, this is a common scenario. We will want to see your prior diagnostic bloodwork, current dose and route, recent monitoring labs, and any imaging or specialist notes. We follow Canadian guidelines for ongoing monitoring as outlined above.

About 90% of straightforward TRT renewal requests are processed within 90 minutes during business hours when there are no significant medical changes since the last prescription and recent monitoring is on file. Initial TRT consultations take longer because the diagnostic workup must be complete and a careful conversation about fertility, monitoring, and ongoing commitment is needed.

No. TeleTest does not provide testosterone or related medications for performance, bodybuilding, or anti-aging reasons. Treatment is offered only for patients who meet guideline criteria for hypogonadism. Non-medical use of androgens raises significant health risks (cardiovascular events, infertility, mood changes, liver issues) and is illegal to prescribe for these indications in Canada.

Total testosterone is everything in the blood, bound and unbound. Free testosterone is the small fraction not bound to any protein - this is the biologically active part. SHBG (the main binding protein) varies enough between individuals that two people with the same total testosterone can have very different free testosterone values. For accurate assessment, both are measured.

Testosterone varies day-to-day. About 20-30% of men with a single low value will have a normal value on a repeat draw. The two-draw rule reduces the chance of treating someone who does not actually have persistently low testosterone.

In general, no. Most over-the-counter supplements marketed as testosterone boosters (zinc, magnesium, fenugreek, ashwagandha, "tribulus," and others) have weak or no good evidence of raising blood testosterone meaningfully. Some have small effects on energy or libido through other mechanisms. They are not a substitute for evaluating and treating genuine low testosterone, and they do not address the cause.

Lifestyle factors that have measurable effects on testosterone:

• Weight loss (especially abdominal weight) - one of the most effective single interventions
• Sleep - getting at least 7-8 hours raises testosterone meaningfully compared to chronic short sleep
• Treating sleep apnea with CPAP can raise levels
• Resistance training has modest short-term effects on testosterone but improves overall endocrine health
• Reducing heavy alcohol use - heavy drinking lowers testosterone
• Reducing chronic stress - sustained cortisol elevation suppresses testosterone
• Avoiding anabolic steroids - the suppression after stopping is severe and can be prolonged

Generally no. Multiple randomized trials have shown that giving testosterone to men with normal testosterone levels does not reliably improve symptoms. If your testosterone is normal, treatment will not help and may cause harm. The right move is to look for the actual cause of the symptoms (sleep, mood, thyroid, anemia, vitamin D, lifestyle).

A young adult with very low testosterone needs a thorough workup before considering treatment. Causes to look for include pituitary issues (high prolactin, pituitary adenoma), genetic conditions (Klinefelter syndrome, hemochromatosis), prior testicular issues, and reversible factors. A referral to an endocrinologist or urologist is often appropriate. Fertility implications are particularly important in this age group.

Fasting is preferred but not strictly required for testosterone alone. Eating tends to lower testosterone modestly for a few hours after a meal. If you are doing a full workup including glucose, HbA1c, and lipids, you will be fasting anyway.

Estradiol is produced from testosterone via the aromatase enzyme. In men on TRT, estradiol can rise and contribute to side effects (breast tenderness, fluid retention). Estradiol is sometimes checked in this monitoring context. Routine estradiol in someone not on TRT is not typically useful unless there are specific symptoms suggesting an issue.

Yes. Some medications used by fertility specialists and urologists stimulate the testicles directly rather than replacing testosterone from outside the body. These approaches can preserve sperm production while addressing low testosterone in someone who wants to maintain fertility. They are specialist-managed and not part of standard TeleTest TRT prescribing. If fertility preservation is a priority, ask for a referral to a urologist or fertility specialist who manages these approaches.

Thyroid disease affects SHBG levels and overall hormonal balance. Untreated hypothyroidism is associated with lower SHBG and altered free testosterone; hyperthyroidism is associated with higher SHBG. Always check TSH in any workup for low testosterone.

Elevated prolactin suppresses LH and therefore testosterone. Causes include certain medications, hypothyroidism, stress, and pituitary adenomas (usually benign and small). Significantly elevated prolactin typically prompts a pituitary MRI. Always check prolactin in the low-testosterone workup.

There is ongoing research about environmental chemicals (some plasticizers, certain pesticides) and their effects on hormones, including testosterone. Population-level data suggest small effects; individual recommendations to "avoid endocrine disruptors" are not well-supported by current evidence. A balanced diet, adequate sleep, regular exercise, and weight management have much larger effects on testosterone than any specific dietary avoidance.

In most provinces, total testosterone is covered under the provincial health plan when ordered for clinical indication. Some panels and add-ons may be self-pay; your TeleTest requisition will indicate what is provincial-billed and what is self-pay before you go to the lab.

For controlled substances (which include some forms of testosterone), Health Canada requires safe disposal of unused medication. Return unused vials, syringes, and used vials to a pharmacy. Do not place them in regular trash or flush them. If you are an established TeleTest patient on injectable therapy, vial return is part of our standard care policy and we will guide you on the schedule.